A nurse is assessing a 7-year-old who has been diagnosed with acute pyelonephritis, what assessment finding requires immediate action by the nurse?
Blood pressure of 136/92 mg
Heart rate of 100 bpm
Decreased urine output
Tea-colored urine
The Correct Answer is A
Rationale:
A. Hypertension (blood pressure of 136/92 mm Hg) in a child with acute pyelonephritis can indicate a severe condition that may lead to renal damage or worsening kidney function. Immediate intervention is necessary to manage high blood pressure and prevent complications.
B. A heart rate of 100 bpm is within normal limits for a 7-year-old and does not require immediate action.
C. Decreased urine output is concerning and needs monitoring, but hypertension is the more urgent issue.
D. Tea-colored urine suggests hematuria or concentrated urine, which is important but not as immediately life-threatening as high blood pressure.
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Correct Answer is B
Explanation
Rationale:
A. A child recovering from nasopharyngitis could still be contagious, and since children with leukemia have compromised immune systems, they are at higher risk of infections.
B. A child with nephrotic syndrome, although potentially needing special care, does not pose the same infection risk as a child recovering from an infectious disease. Therefore, they are a more suitable roommate for a child with leukemia.
C. A child with gastroenteritis may still be infectious and could expose the child with leukemia to gastrointestinal pathogens.
D. A child with rheumatic fever does not have a contagious illness, but the specific needs of the child with leukemia and the potential for complications from infections make it less ideal compared to a non-infectious condition like nephrotic syndrome.
Correct Answer is D
Explanation
Rationale:
A. There is no need to notify the provider if urine output is within the normal range.
B. Oral rehydration may not be necessary if the child is adequately hydrated.
C. A bladder scan is not required if the urine output is within the normal range.
D. Continue to monitor the client as the urine output is within the normal range. For a 3-year-old child (15 kg), normal urine output is 1-2 mL/kg/hr. This child’s output is approximately 1.3 mL/kg/hr, which is normal.