A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid?
Broth
Diluted apple juice
Oral rehydration solution
Water
The Correct Answer is C
A. Broth: While broth can be a source of fluids, it does not contain the appropriate balance of electrolytes needed to rehydrate the body effectively. Gastroenteritis can cause significant fluid and electrolyte loss, so an oral rehydration solution (ORS) with the right proportions of salts and sugars is essential to replace these losses adequately.
B. Diluted apple juice: Diluted apple juice may not provide the proper electrolyte balance needed for rehydration in cases of gastroenteritis. In fact, apple juice is not recommended during episodes of acute gastroenteritis, as it can worsen diarrhea due to its high sugar content. This can lead to further dehydration and discomfort.
C. Oral rehydration solution (ORS): This is the correct answer. Oral rehydration solution is specifically designed to replace lost fluids and electrolytes in cases of gastroenteritis. It contains the right balance of salts and sugars to facilitate effective absorption in the intestines and help rehydrate the body. ORS is the recommended fluid for managing dehydration caused by gastroenteritis in children.
D. Water: While water is essential for hydration, it is not enough to effectively treat dehydration caused by gastroenteritis. Plain water does not contain the necessary electrolytes like sodium, potassium, and chloride, which are lost during episodes of diarrhea and vomiting. Giving water alone may not adequately rehydrate the child and could potentially worsen the dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should recommend bananas as a safe food choice for a 2-year-old child. Bananas are soft and easy to chew, making them safe for young children. They do not pose a choking hazard, unlike grapes, raw carrots, or celery.
Option B (Grapes) can be a choking hazard for young children, especially if they are not cut into small pieces or are given whole.
Option C (Raw carrots) and Option D (Celery) are hard and crunchy, and they require more chewing, which may not be safe for a 2-year-old child who is still developing their chewing and swallowing abilities.
As a general guideline, when selecting foods for young children, it is essential to choose soft, easily chewable, and non-choking hazard options to promote safe eating and reduce the risk of choking incidents.
Correct Answer is D
Explanation
D. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing.
A significant drop in blood pressure when changing positions from lying to standing may indicate orthostatic hypotension, which can be a sign of dehydration, blood loss, or other underlying medical issues. This can be a cause for concern, especially if the client is an adolescent, as it may lead to decreased perfusion of vital organs and may require immediate medical attention.
The other options are as follows:
A. A client who has a burn injury to an estimated 5% of his leg and is crying - While it's essential to assess and address the client's pain and comfort, this finding does not indicate an immediate need for medical attention. Pain management and wound care can be addressed based on the severity of the burn and the client's pain level.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation - This finding is concerning, and the nurse should notify the provider to reassess pain management and evaluate for potential complications related to the fracture. However, it may not require immediate medical attention unless there are signs of severe pain or complications.
C. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F) - A slight increase in temperature in the immediate postoperative period may not be unusual and can be attributed to the normal inflammatory response after surgery. The nurse should continue monitoring the client's temperature and report any further changes or additional signs of infection or complications to the provider.
Overall, while all findings should be addressed and managed appropriately, the significant drop in blood pressure (option D) should be reported immediately due to the potential implications for the client's overall health and well-being.
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