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

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A rationale

Pushing the syringe plunger to empty the formula faster is not recommended. This can lead to complications such as aspiration, diarrhea, or abdominal cramping. The formula should be allowed to flow slowly by gravity.

Choice B rationale

Holding the syringe high enough for the formula to empty gradually by gravity is the correct method for intermittent feeding. This allows for a slow, controlled flow of the formula, which can help prevent complications.

Choice C rationale

Positioning the patient in a supine position during feeding is not recommended. The patient should be in an upright position, at least 30 degrees, to reduce the risk of aspiration.

Choice D rationale

Flushing the tubing before feeding only is not correct. The tubing should be flushed before and after feedings to maintain patency and prevent clogging.

A. Place the client in a supine position. B. Withdraw the tube if the client gags during insertion. C. Instruct the client to place his chin to his chest and swallow. D. Measure the tube for insertion from the tip of the nose to the umbilicus. E. Measure the tube for insertion from the tip of the nose to the umbilicus.

Correct Answer is C

Explanation

Choice A rationale

Placing the client in a supine position is not recommended during nasogastric tube insertion. The client should be in an upright position, such as sitting up or in a high Fowler’s position, to facilitate the passage of the tube and reduce the risk of aspiration.

Choice B rationale

Withdrawing the tube if the client gags during insertion is not the correct action. Gagging is a common reaction during nasogastric tube insertion. The nurse should pause and allow the client to rest and swallow. The tube should only be withdrawn if the client is unable to breathe or is extremely distressed.

Choice C rationale

Instructing the client to place his chin to his chest and swallow can facilitate the passage of the tube through the esophagus. This position closes off the trachea and opens the esophagus, reducing the risk of the tube entering the trachea.

Choice D rationale

Measuring the tube for insertion from the tip of the nose to the umbilicus is not the correct method. The correct measurement is from the tip of the nose to the earlobe and then down to the xiphoid process of the sternum.

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A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following statements is true regarding intermittent feeding?

Correct Answer is B

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The nurse is caring for a client who has a bowel obstruction and a new prescription for the insertion of a nasogastric tube. Which of the following interventions should the nurse take when inserting the nasogastric tube?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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A nurse is planning care for a child who has severe diarrhea.
Which of the following actions is the nurse’s priority?