An 18-month-old is brought to the emergency department with severe dehydration and weight loss secondary to acute diarrhea and vomiting. The nurse knows that therapeutic management of this child will begin with:

Administration of an anti-diarrheal

Clear liquids, 1 to 2 ounces at a time

Oral rehydration solution (ORS)

Intravenous fluids

Answer and Explanation

The Correct Answer is C

Choice A reason: Administration of an anti-diarrheal is not the appropriate management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Anti-diarrheals are not recommended for children under 5 years, as they can have serious side effects, such as paralytic ileus, toxic megacolon, and worsening of dehydration. Anti-diarrheals do not address the underlying cause of diarrhea, and may prolong the duration of infection or toxin exposure.

Choice B reason: Clear liquids, 1 to 2 ounces at a time, are not sufficient to treat an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Clear liquids, such as water, tea, or broth, do not contain enough electrolytes, such as sodium, potassium, and bicarbonate, to replace the losses from diarrhea and vomiting. Clear liquids may also dilute the blood sodium level and cause hyponatremia, a condition of low sodium in the blood, which can lead to seizures, coma, and death.

Choice C reason: Oral rehydration solution (ORS) is the best management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. ORS is a specially formulated solution that contains water, glucose, and electrolytes in the right proportions to replenish the fluid and electrolyte losses from diarrhea and vomiting. ORS can prevent or treat dehydration, and reduce the need for intravenous fluids. ORS can be given by mouth, spoon, cup, or syringe, depending on the child's ability to drink. The amount of ORS to give depends on the degree of dehydration and the weight of the child. The nurse should follow the guidelines from the World Health Organization (WHO) or the local health authority for the appropriate dosage and frequency of ORS administration¹.

Choice D reason: Intravenous fluids are not the first-line management for an 18-month-old with severe dehydration and weight loss secondary to acute diarrhea and vomiting. Intravenous fluids are only indicated for children who have severe dehydration and are unable to drink or tolerate ORS, or who have signs of shock, such as weak pulse, cold extremities, or altered consciousness. Intravenous fluids require hospitalization, skilled personnel, and sterile equipment, and carry the risk of infection, overhydration, or electrolyte imbalance. Intravenous fluids should be given according to the WHO or the local health authority guidelines, and should be switched to ORS as soon as the child is able to drink¹.

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Correct Answer is B

Explanation

Choice A reason: This statement is false. Acetaminophen (Tylenol) is not the best choice for the nurse to administer as an adjuvant to decrease the patient's pain, as acetaminophen is a mild analgesic that works by inhibiting the synthesis of prostaglandins, which are involved in inflammation and pain. Acetaminophen is not very effective for chronic, burning leg pain, which is likely caused by diabetic neuropathy, a nerve damage condition that affects the sensation and function of the legs.

Choice B reason: This statement is true. Gabapentin (Neurontin) is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain, as gabapentin is an anticonvulsant that works by modulating the activity of calcium channels, which are involved in transmitting pain signals from the nerves to the brain. Gabapentin is effective for chronic, burning leg pain, as it can reduce the intensity and frequency of neuropathic pain.

Choice C reason: This statement is false. Hydrocodone-Acetaminophen (Norco) is not the best choice for the nurse to administer as an adjuvant to decrease the patient's pain, as hydrocodone-acetaminophen is a combination of an opioid analgesic and a mild analgesic that works by binding to opioid receptors in the brain and spinal cord, and by inhibiting the synthesis of prostaglandins, respectively. Hydrocodone-acetaminophen is not very effective for chronic, burning leg pain, as it can cause tolerance, dependence, and addiction, and can also interact with oxycodone, which the patient is already taking.

Choice D reason: This statement is false. Aspirin is not the best choice for the nurse to administer as an adjuvant to decrease the patient's pain, as aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that works by inhibiting the synthesis of prostaglandins, which are involved in inflammation and pain. Aspirin is not very effective for chronic, burning leg pain, as it can cause gastrointestinal bleeding, ulcers, and kidney damage, and can also interact with other medications that the patient may be taking, such as anticoagulants or antiplatelets.

A. The patient’s radial pulse is 105 beats/min B. There is sediment and blood in the patient’s urine C. There are crackles throughout both lung fields D. The blood pressure increases from 120/80 to 142/94 mm Hg

Correct Answer is C

Explanation

Choice A reason: This statement is false. The patient’s radial pulse is 105 beats/min is not the assessment data that will require the most rapid response by the nurse. A high pulse rate can indicate dehydration, anxiety, or fever, but it is not a life-threatening condition.

Choice B reason: This statement is false. There is sediment and blood in the patient’s urine is not the assessment data that will require the most rapid response by the nurse. Sediment and blood in the urine can indicate kidney damage, infection, or trauma, but they are not an immediate complication of hyponatremia.

Choice C reason: This statement is true. There are crackles throughout both lung fields is the assessment data that will require the most rapid response by the nurse. Crackles are abnormal lung sounds that indicate fluid accumulation in the alveoli, which can impair gas exchange and cause respiratory distress. Crackles can be a sign of pulmonary edema, a serious complication of hyponatremia that requires prompt treatment.

Choice D reason: This statement is false. The blood pressure increases from 120/80 to 142/94 mm Hg is not the assessment data that will require the most rapid response by the nurse. A high blood pressure can indicate fluid overload, stress, or pain, but it is not a critical condition.

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An 18-month-old is brought to the emergency department with severe dehydration and weight loss secondary to acute diarrhea and vomiting. The nurse knows that therapeutic management of this child will begin with:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who has diabetes and complains of chronic, burning leg pain even when taking oxycodone (OxyContin) twice daily. Which prescribed medication is the best choice for the nurse to administer as an adjuvant to decrease the patient's pain?

Correct Answer is B

Explanation

A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?

Correct Answer is C

Explanation

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