the nurse is caring for a child with acute renal failure what laboratory findings should the nurse expect to find select all that apply

ATI RN

RN Nursing Care of Children 2019 With NGN

1. The nurse is caring for a child with acute renal failure. What laboratory findings should the nurse expect to find? (Select all that apply.)

A. Hyponatremia
B. Hyperkalemia
C. All are applicable
D. Elevated blood urea nitrogen level

Correct answer: C

Rationale: In acute renal failure, laboratory findings typically include hyperkalemia, hyponatremia, and elevated blood urea nitrogen (BUN) levels due to the kidneys' inability to excrete waste and balance electrolytes. Metabolic alkalosis is less common, with metabolic acidosis being more typical.

2. Picking up a pencil demonstrates the ability to use which of the following?

A. Pincer grasp
B. Prehension
C. Parachute reflex
D. Grasp reflex

Correct answer: A

Rationale: Picking up a pencil requires the use of the pincer grasp, which involves the coordination of the thumb and forefinger to hold small objects. The pincer grasp is a fine motor skill essential for tasks that necessitate precision and dexterity. Choices B, C, and D are incorrect. Prehension refers to the act of grasping or holding an object, parachute reflex is a protective response to sudden movement or loss of support, and grasp reflex is an automatic closing of the hand when an object is placed in the palm, none of which specifically relate to the action of picking up a pencil.

3. In the newborn, into what muscle is intramuscular vitamin K administered?

A. Deltoid
B. Dorsogluteal
C. Rectus femoris
D. Vastus lateralis

Correct answer: D

Rationale: In newborns, intramuscular vitamin K is traditionally administered into the vastus lateralis muscle. This site is preferred due to its large muscle mass and accessibility. The dorsogluteal site is not recommended for newborns due to the risk of injury to the sciatic nerve. The deltoid site is also not recommended for newborns. The rectus femoris muscle is not commonly used for intramuscular injections in newborns.

4. Which best describes signs and symptoms as part of a nursing diagnosis?

A. Description of potential risk factors
B. Identification of actual health problems
C. Human response to state of illness or health
D. Cues and clusters derived from patient assessment

Correct answer: D

Rationale: Signs and symptoms are cues and clusters derived from patient assessments that are used to form a nursing diagnosis, guiding the development of a care plan.

5. Which actions by the nurse demonstrate clinical reasoning? (Select all that apply.)

A. All below
B. Considering alternative actions
C. Using formal and informal thinking to gather data
D. Giving deliberate thought to a patient's problem

Correct answer: A

Rationale: Clinical reasoning involves deliberate and thoughtful decision-making, considering alternatives, and using both formal and informal data gathering methods to provide optimum care.