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 D
Explanation
Choice A rationale:
Monitoring the patient's breathing pattern at 15-minute intervals is crucial in an unconscious patient who may have ingested alcohol or drugs, as it helps assess their respiratory status. This intervention ensures early detection of any respiratory distress and guides necessary interventions.
Choice B rationale:
Inserting an indwelling Foley catheter for straight drainage is appropriate for unconscious patients to monitor their urinary output and renal function. This helps prevent urinary retention and complications related to inadequate urine elimination.
Choice C rationale:
Administering IV D5/45 NS at 100 mL/hr is a suitable intervention to maintain the patient's fluid and electrolyte balance. It prevents dehydration and supports hemodynamic stability.
Choice D rationale:
The nurse should question the prescription of syrup of ipecac. Ipecac is no longer recommended for use in cases of poisoning due to its potential to cause adverse effects like aspiration, electrolyte imbalances, and delayed treatment. Activated charcoal or gastric lavage may be more appropriate in this situation.
Correct Answer is B
Explanation
Choice A rationale:
The statement "I will not take medications in front of my child”. is correct. Caregivers should avoid taking medications in front of children to prevent them from mimicking the behavior, as some medications can be harmful if ingested accidentally.
Choice B rationale:
The statement "I will keep all my medications in my purse”. is incorrect. Keeping medications in a purse or easily accessible place poses a risk of accidental ingestion by the child. Medications should be stored out of reach and in child-resistant containers.
Choice C rationale:
The statement "We will safety-proof the grandparents' house”. is correct. Safety-proofing the environment is important to prevent accidental poisoning. This statement demonstrates caregiver awareness of potential risks in another household.
Choice D rationale:
The statement "We will put locks on all of our cabinet doors at home”. is correct. Locking cabinet doors is a preventive measure to keep children away from potentially harmful substances, showcasing the caregiver's understanding of safety precautions.
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