The nurse is to record the intake and output of a 2-year-old patient. The patient is not toilet trained. Which measure would be most appropriate to include in the patient's plan of care?
Obtaining an order to have an indwelling urinary catheter inserted.
Weighing the patient's wet diapers prior to discarding them.
Sitting the patient on the bedpan at least every two hours.
Applying a pediatric urine collection device over the patient's urinary meatus.
The Correct Answer is B
Weighing the patient's wet diapers prior to discarding them.
Choice A rationale:
Inserting an indwelling urinary catheter is invasive and not appropriate for a non-toilet-trained 2-year-old unless medically necessary.
Choice B rationale:
Weighing wet diapers is the most accurate way to measure urine output in a young child who isn't toilet trained. This method provides essential information for assessing hydration and kidney function.
Choice C rationale:
Sitting the patient on the bedpan every two hours is suitable for older children but may not be effective or tolerable for a 2-year-old.
Choice D rationale:
Applying a pediatric urine collection device is an option, but it might not be as accurate as weighing wet diapers and may cause discomfort for the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.
Choice B rationale:
IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.
Choice C rationale:
The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.
Choice D rationale:
Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.
Correct Answer is D
Explanation
Choice A rationale:
Wet diapers are a sign of hydration, not necessarily nutrition sufficiency.
Choice B rationale:
Introducing solids too early can lead to various issues; it's not linked to sleep improvement.
Choice C rationale:
Cow's milk isn't suitable for a newborn's consumption due to the potential for allergies and digestive issues.
Choice D rationale:
This choice accurately reflects hunger cues in a newborn, demonstrating an understanding of proper feeding.
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