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A nurse is assisting with the care of a 2-year-old child.

Which of the following actions should the nurse take when assisting with the implementation of the plan of care? Select all that apply.

Initiate NPO status

Maintain IV fluids.

Maintain strict intake and output.

Weigh the child daily.

Instruct the guardian about proper hand hygiene.

Check the child's temperature rectally.

Monitor laboratory values.

Answer and Explanation

Correct Answer : B,C,D,E,G

A. Initiate NPO status: The child is already unable to tolerate oral intake due to vomiting, but routine NPO status is not always necessary unless prescribed. With mild to moderate dehydration, oral rehydration may be attempted if tolerated, and withholding all fluids could worsen fluid deficit.

B. Maintain IV fluids: The child demonstrates signs of moderate dehydration, including weight loss, sunken eyes, delayed skin turgor, and reduced urine output. IV fluid therapy is necessary to restore intravascular volume, correct electrolyte imbalances, and prevent progression to hypovolemic shock.

C. Maintain strict intake and output: Accurate monitoring of fluid intake and urine/stool output is critical to assess hydration status and guide IV fluid replacement. The child’s ongoing diarrhea and low urine output indicate the need for close tracking to prevent further fluid deficit.

D. Weigh the child daily: Daily weight measurement is an objective and sensitive indicator of hydration status in pediatric clients. The child’s 0.5 kg (1 lb) weight loss over 24 hours reflects significant fluid loss and helps guide ongoing fluid management.

E. Instruct the guardian about proper hand hygiene: The child has a confirmed Escherichia coli infection, which is highly transmissible via the fecal–oral route. Educating the guardian about proper handwashing helps prevent spread to others and reinforces infection control practices.

F. Check the child's temperature rectally: Rectal temperature measurement is invasive and may increase discomfort or risk of injury, especially in a drowsy or irritable toddler. Oral or axillary methods are safer and sufficient for routine monitoring.

G. Monitor laboratory values: Electrolytes, BUN, creatinine, and other relevant labs are crucial to assess the severity of dehydration, renal perfusion, and metabolic disturbances. Trends in these values guide fluid and electrolyte replacement and indicate improvement or deterioration.

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Correct Answer is A

Explanation

A. A 2-month-old infant: The DTaP vaccine series begins at 2 months of age according to the routine immunization schedule. Administering the first dose at this age provides early protection against diphtheria, tetanus, and pertussis, which can be severe in young infants. Subsequent doses are given at 4 months, 6 months, and booster doses at later intervals.

B. A 4-month-old infant: At 4 months, the infant is due for the second DTaP dose, not the initial dose. Administering the vaccine at this age without a prior first dose would be incomplete, as the series is designed to build immunity progressively from 2 months onward.

C. A 6-month-old infant: The 6-month visit typically coincides with the third DTaP dose in the primary series. The initial dose must have been administered at 2 months, making this age inappropriate for starting the series.

D. A 15-month-old toddler: By 15 months, the primary DTaP series should already be completed with a fourth dose administered between 15–18 months. Initiating the series at this age would require catch-up immunization protocols rather than the standard initial vaccination schedule.

A. Tachycardia B. Mental alertness C. Hyperreflexia D. Pinpoint pupils

Correct Answer is D

Explanation

A. Tachycardia: Opioid intoxication typically causes bradycardia rather than tachycardia due to central nervous system depression and increased parasympathetic activity. Elevated heart rate is more commonly associated with stimulant use or withdrawal states, not opioid intoxication.

B. Mental alertness: Opioids depress the central nervous system, leading to drowsiness, sedation, or stupor. Mental alertness is not consistent with opioid intoxication; instead, clients often present with decreased responsiveness and impaired cognition.

C. Hyperreflexia: Opioid intoxication generally causes decreased reflexes due to CNS depression. Hyperreflexia is more characteristic of stimulant intoxication or opioid withdrawal, not acute opioid toxicity.

D. Pinpoint pupils: Miosis, or constricted pupils, is a classic sign of opioid intoxication. Opioids stimulate the parasympathetic system via the Edinger-Westphal nucleus, causing the pupils to constrict. This is a reliable clinical indicator of opioid effects and is used in assessment of intoxication.

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Which of the following actions should the nurse take when assisting with the implementation of the plan of care? Select all that apply.