A nurse is planning care for a toddler who was admitted for acute diarrhea. Which of the following actions is the nurse's priority?
Initiating IV fluid therapy
Administering a regular diet
Administering IV antibiotics
Initiating oral rehydration therapy
The Correct Answer is D
A. IV fluid therapy may be necessary if the child cannot tolerate oral fluids, but oral rehydration therapy is the first line of treatment for mild to moderate dehydration.
B. Administering a regular diet is important for recovery but is not the priority action when addressing acute dehydration.
C. IV antibiotics are not typically necessary for acute diarrhea unless there is a confirmed bacterial infection.
D. Initiating oral rehydration therapy is the priority to address dehydration and replace lost fluids and electrolytes effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administering bronchodilator therapy immediately before chest physiotherapy helps open the airways, making the therapy more effective.
B. Administering the bronchodilator 2 hours before is too early to have the desired effect during physiotherapy.
C. Administering the bronchodilator 2 hours after does not support the immediate effectiveness of chest physiotherapy.
D. Administering the bronchodilator immediately after chest physiotherapy does not provide the benefit needed during the procedure.
Correct Answer is C
Explanation
A. Nasal discharge negative for glucose indicates that there is no cerebrospinal fluid (CSF) leakage, which is a positive sign. While it is important to note, it is not the priority in this situation.
B. A negative Babinski reflex is a normal finding in children older than 2 years. It does not indicate an acute issue and is not the priority.
C. Asymmetric pupils can be a sign of increased intracranial pressure or a serious brain injury, making this the priority finding. It requires immediate attention to prevent further complications.
D. A 2 cm scalp laceration, while needing medical attention, is not life-threatening and is not the highest priority compared to potential brain injury indicated by asymmetric pupils.
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