A nurse is planning care for a child who has severe diarrhea.
Which of the following actions is the nurse’s priority?
Introduce a regular diet
Maintain fluid therapy
Rehydrate
Assess fluid balance
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Introducing a regular diet is not the immediate priority for a child with severe diarrhea. The focus should be on stabilizing the child’s condition before reintroducing regular foods.
Choice B rationale:
Maintaining fluid therapy is important, but it is part of the broader goal of managing fluid balance. It is not the first step in addressing severe diarrhea.
Choice C rationale:
Rehydration is crucial, but it falls under the broader category of assessing and managing fluid balance. Ensuring the child is properly hydrated is part of the overall assessment.
Choice D rationale:
Assessing fluid balance is the priority action. This involves evaluating the child’s hydration status, monitoring for signs of dehydration, and ensuring that fluid therapy is appropriately managed. This step is critical to prevent complications from severe diarrhea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A decrease in systolic blood pressure is not a physiological change that increases the risk of dehydration in older adults.
Choice B rationale
An increase in saliva production does not occur with aging and does not increase the risk of dehydration.
Choice C rationale
An increase in the percentage of body water does not occur with aging. In fact, total body water decreases with age, which can contribute to an increased risk of dehydration.
Choice D rationale
A decrease in kidney function is a common physiological change that occurs with aging. This can lead to a decreased ability to concentrate urine and conserve water, increasing the risk of dehydration.
Correct Answer is A
Explanation
Choice A rationale
Placing clean linen that touched the floor in the soiled linen bag is a correct practice. This is because the floor is considered dirty, and any linen that comes into contact with it should be considered contaminated.
Choice B rationale
Shaking soiled linen to remove any toilet paper remnants is not a correct practice. Shaking soiled linen can disperse pathogens into the air, increasing the risk of disease transmission.
Choice C rationale
Placing the soiled linen on the floor before bagging it is not a correct practice. Soiled linen should be handled as little as possible and placed directly into a designated, leak-proof container.
Choice D rationale
Holding the soiled linen against her body while carrying it to the linen bag is not a correct practice. Soiled linen should be handled carefully to avoid contact with the body, as this can lead to contamination of the worker’s clothing and potentially spread infection.
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