Difficulty: Medium
Average Score: 87%
Simulated
Passage / Scenario
A 3-year-old child who has had 160 mL of urine output over the past 8 hr period and weighs 33 lbA nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8 hr period. The child weighs 33 lb. Which of the following actions should the nurse take?
Correct answer
A
Rationale
The correct answer is A: Continue to monitor the client. In a 3-year-old child, the expected urine output is approximately 1 mL per kg per hour. In this case, the child weighs 33 lb, which is roughly 15 kg. So, the expected urine output over 8 hours would be around 120 mL. The child's actual urine output of 160 mL over 8 hours is within the expected range, indicating adequate renal function. Therefore, there is no immediate concern, and the nurse should continue to monitor the client for any changes.
Option B: Notifying the provider is unnecessary as the urine output is within the expected range.
Option C: Providing oral rehydration fluids is not indicated as the child's urine output is adequate.
Option D: Performing a bladder scan is not necessary at this point as there are no indications of urinary retention.
Option B: Notifying the provider is unnecessary as the urine output is within the expected range.
Option C: Providing oral rehydration fluids is not indicated as the child's urine output is adequate.
Option D: Performing a bladder scan is not necessary at this point as there are no indications of urinary retention.