A nurse is caring for a child who has had diarrhea for 3 days.
Which of the following actions should the nurse take?
Collect a stool culture.
Offer the child 120 mL (4 oz) of apple juice every 2 hr.
Keep the child NPO for the next 12 hr.
Weigh the child weekly.
The Correct Answer is A
Choice A rationale
Collecting a stool culture is important for identifying the causative agent of diarrhea, such as bacteria, viruses, or parasites. This information is critical for determining the appropriate treatment and managing the child's symptoms effectively.
Choice B rationale
Offering apple juice or other sugary drinks can exacerbate diarrhea by drawing more fluid into the intestines and increasing stool frequency. Oral rehydration solutions are preferred.
Choice C rationale
Keeping the child NPO (nothing by mouth) for an extended period is not recommended, as it can lead to dehydration and does not address the underlying cause of diarrhea.
Choice D rationale
Weighing the child weekly is not sufficient for monitoring the immediate effects of diarrhea, such as dehydration and weight loss. More frequent assessments are necessary during acute episodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Vesicles on the trunk are indicative of varicella (chickenpox) rather than respiratory syncytial virus (RSV). RSV typically causes respiratory symptoms rather than skin manifestations like vesicles.
Choice B rationale
Rhinorrhea (runny nose) is a common symptom of RSV in infants. It is part of the upper respiratory symptoms caused by the virus, alongside coughing and wheezing.
Choice C rationale
Barrel chest is more associated with chronic conditions like cystic fibrosis or severe, long-standing asthma, not acute infections like RSV. RSV primarily affects the bronchioles, leading to bronchiolitis.
Choice D rationale
Clubbing of the fingers is generally a sign of chronic hypoxia and is seen in long-term conditions such as congenital heart disease or cystic fibrosis, rather than acute RSV infection. .
Correct Answer is A
Explanation
Choice A rationale
Ibuprofen should be clarified before administration to a 5-month-old infant. Ibuprofen is not recommended for infants younger than 6 months due to the risk of adverse effects on the kidneys and gastrointestinal tract. Infants have immature renal function, and administering ibuprofen can increase the risk of nephrotoxicity. Additionally, ibuprofen can cause gastric irritation and increase the risk of gastrointestinal bleeding. The nurse should verify the safety and appropriateness of this medication with the prescribing healthcare provider before administration.
Choice B rationale
Acetaminophen is generally considered safe for use in infants to reduce fever and alleviate pain. It is often the preferred antipyretic for infants younger than 6 months due to its favorable safety profile. Acetaminophen does not have the same risks of nephrotoxicity and gastrointestinal irritation as ibuprofen, making it a suitable choice for managing fever in this age group.
Choice C rationale
The heart rate of 84/min is within the normal range for a 5-month-old infant. Heart rate itself is not a medication and does not require clarification. Instead, it is a vital sign that should be monitored to assess the infant's overall condition and response to treatment.
Choice D rationale
Temperature itself is not a medication and does not require clarification. It is a vital sign that indicates the body's response to infection or inflammation. The nurse should monitor the infant's temperature and provide appropriate interventions, such as antipyretics like acetaminophen, to manage fever. .
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