A nurse is caring for a child who has had diarrhea for 3 days. Which of the following actions should the nurse take?

Weigh the child weekly.

Keep the child NPO for the next 12 hr.

Collect a stool culture.

Offer the child 120 mL (4 oz) of apple juice every 2 hr.

Answer and Explanation

The Correct Answer is C

A. Weighing the child weekly is not an appropriate intervention for managing acute diarrhea, as it does not address the immediate concern of dehydration or infection.

B. Keeping the child NPO for 12 hours is generally not recommended unless the child is severely dehydrated or vomiting, as it could lead to further dehydration. Hydration and appropriate refeeding are important in managing diarrhea.

C. A stool culture can help determine the cause of diarrhea (such as bacterial infection) and guide appropriate treatment. This is a priority in determining the underlying cause of the child's symptoms.

D. Offering apple juice is not recommended for diarrhea, as high fructose content can worsen diarrhea. Oral rehydration solutions (ORS) or clear fluids are more appropriate.

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Correct Answer is A

Explanation

A. Infants with heart failure may experience fatigue during feeding, so smaller, more frequent feedings are recommended to prevent exhaustion and ensure adequate nutrition. Feedings every 3 hours are typically recommended to maintain a steady intake without overexertion.

B. Diluting formula to half strength is not recommended for an infant with heart failure, as it can lead to malnutrition and insufficient caloric intake. The formula should be provided at normal strength.

C. Placing the infant in a lateral position during feeding could be unsafe, as it may increase the risk of aspiration. The infant should generally be fed in an upright or semi-upright position to reduce aspiration risk and promote optimal digestion.

D. Bolus gavage feedings are typically used for infants who are unable to feed orally due to medical conditions, but for a child with heart failure who is feeding orally, more frequent and smaller feedings would be preferable.

A. Apply calamine lotion to the affected area. B. Flush the area with cold, running water. C. Instruct the parent to give the child an oatmeal bath twice daily. D. Administer an oral corticosteroid.

Correct Answer is B

Explanation

A. Applying calamine lotion is helpful for symptom relief but does not remove the poison ivy oil from the skin.

B. Flushing the affected area with cold, running water immediately after exposure helps to remove the poison ivy oil (urushiol) from the skin, which is crucial in preventing or reducing the severity of the rash.

C. While an oatmeal bath can help soothe itching, it is not the priority action in the acute stage of exposure.

D. Administering an oral corticosteroid may be necessary if the rash is severe, but flushing the area with water should be the first step in preventing further reaction.

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A nurse is caring for a child who has had diarrhea for 3 days. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for an infant who has heart failure. Which of the following interventions should the nurse recommend?

Correct Answer is A

Explanation

A nurse is caring for a child who is brought to the urgent care clinic following exposure to poison ivy 1 hr ago. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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