A nurse is caring for a child who has mild dehydration due to an Escherichia coli infection. Which of the following actions should the nurse take?
Encourage intake of fruit juices.
Give 2 tsp of oral rehydration solution every 5 to 10 min.
Administer promethazine as needed.
Offer one banana and 1/2 cup of rice with each meal.
The Correct Answer is B
Choice A reason:
Encouraging fruit juices is not the best approach for rehydration in a child with mild dehydration. Fruit juices can be high in sugar and may worsen diarrhea.
Choice B reason:
Giving oral rehydration solution in small, frequent amounts is the recommended treatment for mild dehydration due to infection. This helps replace lost fluids and electrolytes.
Choice C reason:
Promethazine is not indicated for the treatment of dehydration. It is an antihistamine and antiemetic, but it does not address the underlying issue of fluid loss.
Choice D reason:
Offering banana and rice can be part of a bland diet after rehydration, but it does not address the immediate need for replenishing lost fluids and electrolytes. The priority is to start with oral rehydration solution.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
At 18 months, a toddler should typically be saying more than four words. This finding may
indicate a potential delay in speech development, and it should be reported to the provider for further evaluation.
Choice B reason:
Building a tower of three blocks is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Choice C reason:
Temper tantrums are a normal behavior for toddlers, as they are still developing emotional regulation skills. This finding does not require reporting unless it is severe or causing harm to the child.
Choice D reason:
Jumping in place with both feet is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.
Correct Answer is C
Explanation
Choice A reason:
Reducing fiber intake is not necessary for a client in skeletal traction. Maintaining a balanced diet, including fiber, is important for overall health.
Choice B reason:
The nurse should not lift the traction weights off the floor. The weights must hang freely to provide the necessary traction.
Choice C reason:
Performing passive range-of-motion exercises helps prevent stiffness and muscle atrophy in the affected extremity. This is an important nursing intervention for a client in skeletal traction.
Choice D reason:
Applying protective padding to the pin sites is essential to prevent pressure and irritation. However, this action alone does not address the need for range-of-motion exercises.
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