The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What is the most appropriate initial nursing action?

The correct answer is choice C: Oral rehydration solution (ORS).

Choice A rationale:

Clear liquids, 1 to 2 ounces at a time, might not be sufficient to adequately rehydrate a child with severe dehydration. Clear liquids lack the necessary electrolytes and glucose content to effectively combat dehydration and replace lost fluids.

Choice B rationale:

Administration of antidiarrheal medication is not the initial step in managing severe dehydration caused by acute diarrhea and vomiting. Antidiarrheal medications can slow down the gastrointestinal motility, which may exacerbate the problem by delaying the elimination of the causative agent and prolonging the dehydration.

Choice C rationale:

Oral rehydration solution (ORS) is the recommended initial intervention for managing severe dehydration caused by acute diarrhea and vomiting. ORS contains the appropriate balance of electrolytes (sodium, potassium, chloride) and glucose to replace lost fluids and electrolytes, thereby helping to rehydrate the child effectively. It is absorbed even when digestion is impaired due to the illness.

Choice D rationale:

Intravenous fluids might be necessary if the child's condition is very severe and oral intake cannot be maintained. However, it's not the first-line intervention. Oral rehydration is preferred whenever feasible because it is less invasive and can be administered even in mild to moderate dehydration cases.

The correct answer is choice B. Reduce gastric acid production.

Choice A rationale:

Preventing reflux is not the primary purpose of prescribing a histamine receptor antagonist. Histamine receptor antagonists work by reducing gastric acid production, which in turn can help alleviate symptoms of gastroesophageal reflux disease (GERD). They do not directly prevent the physical reflux of stomach contents into the esophagus.

Choice B rationale:

The primary purpose of prescribing a histamine receptor antagonist for an infant diagnosed with gastroesophageal reflux is to reduce gastric acid production. Histamine stimulates acid secretion in the stomach, and these medications (e.g., ranitidine, famotidine) block histamine receptors on stomach cells, leading to decreased acid secretion. This helps reduce the acidity of stomach contents that could contribute to esophageal irritation in GERD.

Choice C rationale:

Preventing hematemesis (vomiting blood) is not a primary action of histamine receptor antagonists. While reducing gastric acid production might indirectly help prevent complications such as bleeding due to irritation and inflammation of the esophagus, it's not the main purpose of these medications.

Choice D rationale:

Increasing gastric acid production is the opposite of the intended effect of histamine receptor antagonists. These medications are specifically used to decrease gastric acid production and provide relief from conditions where excess acid is causing problems, such as GERD.