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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Broth is a clear liquid that can help replace sodium and chloride lost through diarrhea. However, it does not contain the necessary amounts of other electrolytes such as potassium and bicarbonate, which are also commonly lost in diarrhea.
Choice B rationale
Apple juice is not a good choice for a child with acute diarrhea. It is high in sugars and can worsen diarrhea. It also does not contain the electrolytes needed to replace those lost through diarrhea.
Choice C rationale
Cherry gelatin is not a suitable choice. While it is a clear liquid that can help with hydration, it does not contain the necessary electrolytes to replace those lost through diarrhea. It is also high in sugars, which can worsen diarrhea.
Choice D rationale
Pedialyte is the best choice for a child with acute diarrhea who reports that he is thirsty. It is a rehydration solution specifically designed to replace fluids and electrolytes lost through diarrhea.
Correct Answer is C
Explanation
Platelet count is not the primary diagnostic test used to monitor the therapy’s effect of warfarin. Platelets are involved in the clotting process, but warfarin specifically works by inhibiting the synthesis of vitamin K-dependent clotting factors, which does not directly involve platelets.
Choice B rationale
The white blood cell count (WBC) is not used to monitor the effect of warfarin therapy. WBC is typically used to monitor for infection or inflammation, not the coagulation status of a patient.
Choice C rationale
Prothrombin time (PT) is the correct answer. Warfarin therapy is monitored using the PT, which is reported as the International Normalized Ratio (INR). Warfarin inhibits the synthesis of vitamin K-dependent clotting factors, which include Factors II, VII, IX, and X, and Proteins C and S. The PT/INR is sensitive to changes in these factors. An elevated INR indicates a higher risk of bleeding, while a lower INR suggests a higher risk of clotting.
Choice D rationale
Activated partial thromboplastin time (aPTT) is not typically used to monitor warfarin therapy. The aPTT test evaluates the intrinsic and common pathways of coagulation, which includes factors XII, XI, IX, VIII, X, V, II (prothrombin), and I (fibrinogen). Warfarin affects the extrinsic pathway and common pathway, not the intrinsic pathway. Therefore, aPTT is not the best test to monitor the effects of warfarin.
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