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 A
Explanation
Choice A rationale
Performing hand hygiene frequently and consistently is the most effective way to prevent the spread of pathogens during patient care. Hand hygiene is the single most important measure to reduce the transmission of harmful germs and prevent health care-associated infections.
Choice B rationale
Properly disposing of contaminated equipment is important in preventing the spread of pathogens, but it is not the most effective measure. While it is crucial to handle and dispose of contaminated equipment properly, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice C rationale
Discarding used syringes in appropriate containers is a standard safety measure in healthcare settings, but it is not the most effective way to prevent the spread of pathogens during patient care. While it is important for preventing needlestick injuries and the spread of bloodborne pathogens, hand hygiene is the most effective measure in preventing the spread of pathogens.
Choice D rationale
Changing soiled linens daily for patients with draining wounds is a part of standard wound care and infection control, but it is not the most effective way to prevent the spread of pathogens during patient care. Hand hygiene remains the most effective measure in preventing the spread of pathogens.
Correct Answer is B
Explanation
Choice A rationale
Airborne precautions are used for diseases that are spread by tiny droplets caused by coughing and sneezing. HIV is not spread through the air, so airborne precautions are not necessary.
Choice B rationale
Standard precautions are used for all patient care. They’re based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. HIV is transmitted by direct or indirect contact with infected blood or body fluids. Therefore, the nurse should plan to implement standard precautions when caring for this patient.
Choice C rationale
Droplet precautions are used for diseases that are spread by large droplets caused by coughing, sneezing, talking, or procedures such as suctioning and bronchoscopy. HIV is not spread through these methods, so droplet precautions are not necessary.
Choice D rationale
Contact precautions are used for diseases that are spread by direct contact with the patient or indirect contact with environmental surfaces or patient care items. HIV is not spread through casual contact, so contact precautions are not necessary.
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