A patient with gastroenteritis is experiencing persistent vomiting and diarrhea. Which nursing intervention should be prioritized to prevent complications associated with hypovolemia?
Encourage the patient to eat solid foods to regain energy.
Initiate intravenous fluid therapy to restore fluid balance.
Administer antiemetic medication to control vomiting.
Monitor the patient's weight daily to assess fluid status.
The Correct Answer is B
Rationale:
A. Encouraging the patient to eat solid foods may be appropriate once vomiting has subsided, but during active gastroenteritis with persistent vomiting and diarrhea, oral intake is often insufficient to prevent dehydration. Relying on food alone does not address acute fluid loss.
B. Initiating intravenous (IV) fluid therapy is the priority intervention. Persistent vomiting and diarrhea can lead to rapid fluid and electrolyte loss, resulting in hypovolemia, hypotension, tachycardia, and potential shock. IV fluids provide immediate restoration of circulating volume, correct electrolyte imbalances, and prevent life-threatening complications.
C. Administering antiemetics can help reduce nausea and vomiting, but it does not correct the underlying fluid deficit. While controlling vomiting supports oral intake, IV fluid replacement is more urgent to stabilize the patient.
D. Monitoring daily weight is useful for tracking fluid balance, but it is a secondary assessment tool. It does not intervene in acute hypovolemia and cannot replace prompt fluid resuscitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Alcohol and caffeine are well-known risk factors that worsen GERD symptoms. Both substances can decrease lower esophageal sphincter (LES) tone, allowing gastric contents to reflux into the esophagus. They can also increase gastric acid secretion and irritate the esophageal mucosa. Teaching clients to limit or avoid alcohol and caffeine is a key component of GERD education.
B. Lying down after eating does increase the risk of GERD symptoms. When a person lies flat, gravity no longer helps keep stomach contents in the stomach, making reflux more likely. Clients with GERD are advised to remain upright for at least 2–3 hours after meals and to elevate the head of the bed.
C. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the gastric and esophageal mucosa and may worsen GERD symptoms or increase the risk of gastrointestinal bleeding. Therefore, it is not advisable to take aspirin routinely if GERD is present unless specifically prescribed.
D. Mercury-containing foods, such as certain seafood, are not associated with GERD symptoms. Dietary triggers for GERD are related to acid production, LES relaxation, and mucosal irritation.
Correct Answer is C
Explanation
Rationale:
A. Weight fluctuations are not a common side effect of hydroxychloroquine. While chronic disease activity, dietary changes, or concurrent medications may influence a client’s weight, hydroxychloroquine itself is not known to cause significant weight gain or loss. Monitoring weight may still be part of overall health assessment in rheumatoid arthritis, but it is not a primary concern related to this medication.
B. High cholesterol is not directly associated with hydroxychloroquine use. Some disease-modifying anti-rheumatic drugs (DMARDs) or long-term corticosteroid therapy may affect lipid metabolism, but hydroxychloroquine generally does not alter cholesterol or lipid profiles. Cardiovascular risk assessment is important in rheumatoid arthritis, but hyperlipidemia is not a direct medication effect.
C. Eye problems are a well-recognized potential complication of hydroxychloroquine therapy. The drug can cause retinopathy, blurred vision, difficulty distinguishing colors, or changes in night vision, particularly with long-term use or higher cumulative doses. Retinal toxicity is irreversible if not detected early, so clients should undergo a baseline ophthalmologic examination before starting therapy and periodic follow-up exams (usually annually after 5 years of use, or sooner if risk factors are present). Nurses should educate clients to report any visual changes immediately, including blurred vision, difficulty reading, or changes in peripheral vision.
D. Development of ulcers is not a typical side effect of hydroxychloroquine. Gastrointestinal upset such as nausea, abdominal discomfort, or diarrhea may occur, but these are generally mild and manageable. Peptic or gastric ulcers are not directly related to hydroxychloroquine therapy.
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