A nurse in a community clinic is collecting data from a patient who reports frequent vomiting and diarrhea for the past 3 days.
Which of the following findings should the nurse expect? (Select all that apply.)

Hypotension

Bradycardia

Pale yellow urine

Poor skin turgor

Flat neck veins

Answer and Explanation

Correct Answer : A,D,E

A.   Hypotension: Frequent vomiting and diarrhea can cause dehydration, which can lead to hypotension.
B.   Bradycardia: Bradycardia is not typically a symptom of dehydration caused by vomiting and diarrhea.
C.   Pale yellow urine: Dehydration can cause urine to become concentrated, resulting in a darker color, not pale yellow.
D.   Poor skin turgor: Dehydration can cause poor skin turgor, which is skin that lacks elasticity.
E.   Flat neck veins: Dehydration can cause flat neck veins when the patient is lying supine.

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Correct Answer is D

Explanation

Choice A rationale

Broth is a clear liquid that can help replace sodium and chloride lost through diarrhea. However, it does not contain the necessary amounts of other electrolytes such as potassium and bicarbonate, which are also commonly lost in diarrhea.

Choice B rationale

Apple juice is not a good choice for a child with acute diarrhea. It is high in sugars and can worsen diarrhea. It also does not contain the electrolytes needed to replace those lost through diarrhea.

Choice C rationale

Cherry gelatin is not a suitable choice. While it is a clear liquid that can help with hydration, it does not contain the necessary electrolytes to replace those lost through diarrhea. It is also high in sugars, which can worsen diarrhea.

Choice D rationale

Pedialyte is the best choice for a child with acute diarrhea who reports that he is thirsty. It is a rehydration solution specifically designed to replace fluids and electrolytes lost through diarrhea.

A. Request the providers to initiate antibiotic therapy for every patient on the unit. B. Perform hand hygiene with an alcohol-based agent. C. Obtain stool cultures from all patients on the nursing unit. D. Place all patients who have symptoms on contact precautions.

Correct Answer is D

Explanation

Choice A rationale

Requesting the providers to initiate antibiotic therapy for every patient on the unit is not the most appropriate action. Antibiotics should only be used when there is a confirmed bacterial infection. Overuse of antibiotics can lead to antibiotic resistance and can potentially trigger C. difficile infection due to disruption of normal gut flora.

Choice B rationale

While performing hand hygiene with an alcohol-based agent is important in general infection control, it is not the most effective measure against C. difficile.

C. difficile spores are resistant to destruction by alcohol-based hand rubs. Therefore, hand hygiene for C. difficile should involve washing with soap and water.

Choice C rationale

Obtaining stool cultures from all patients on the nursing unit is not the most appropriate action. Stool cultures should be obtained from patients who are symptomatic. Testing asymptomatic patients can lead to false positives and unnecessary treatment.

Choice D rationale

Placing all patients who have symptoms on contact precautions is the correct answer. Contact precautions, including the use of gloves and gowns, can prevent the spread of C. difficile. This is because C. difficile is spread via the fecal-oral route, and its spores can survive on surfaces for long periods.

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A nurse in a community clinic is collecting data from a patient who reports frequent vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child?

Correct Answer is D

Explanation

Choice A rationale

Choice C rationale

Choice D rationale

A nurse on a medical-surgical unit suspects that several patients have Clostridium difficile (C. difficile) when they all develop watery diarrhea. What actions should the nurse plan to take while waiting for the patients’ lab results?

Correct Answer is D

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse in a community clinic is collecting data from a patient who reports frequent vomiting and diarrhea for the past 3 days.
Which of the following findings should the nurse expect? (Select all that apply.)