A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
Initiate isotonic fluids with 20 mEq/L potassium chloride.
Collect a stool sample from the toddler.
Determine if the toddler is voiding.
Request evaluation of the toddler’s serum electrolytes.
The Correct Answer is C
The correct answer is (C) Determine if the toddler is voiding.
Choice A: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child’s hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children.
Choice B: Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child’s hydration status needs to be assessed.
Choice C: Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child’s hydration status, which is critical in managing acute gastroenteritis.
Choice D: Request evaluation of the toddler’s serum electrolytes Requesting an evaluation of the toddler’s serum electrolytes is also important, but it’s typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child’s hydration status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Bending forward from the waist with the head and arms downward, also known as the Adams forward bend test, is the standard screening test for scoliosis.
Choice B rationale
Touching the chin to the chest and then looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening.
Choice C rationale
Lying prone on the examination table is not a standard position for scoliosis screening.
Choice D rationale
Turning to the side and remaining in a relaxed position is not a standard position for scoliosis screening.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Cold compresses can help relieve joint pain associated with juvenile idiopathic arthritis. Cold therapy can reduce inflammation and numb the affected area, providing temporary relief.
Choice B rationale
This is incorrect. Ibuprofen should not be taken on an empty stomach because it can cause stomach upset or even lead to ulcers or bleeding. It is generally recommended to take ibuprofen with food or milk.
Choice C rationale
Performing range of motion exercises can help maintain joint flexibility and muscle strength in children with juvenile idiopathic arthritis. Regular exercise can also improve overall physical function and well-being.
Choice D rationale
While homeschooling may be a consideration for some families, it is not a general recommendation for all children with juvenile idiopathic arthritis. Many children with this condition can attend regular school with some accommodations as needed.
Choice E rationale
This is correct. Providing extra time for completion of activities of daily living (ADLs) can help children with juvenile idiopathic arthritis manage their symptoms and maintain their independence. It is important to allow children to perform tasks at their own pace to avoid causing unnecessary pain or fatigue.
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