The physician has ordered replacement fluids for a client who has a fluid volume deficit with a diagnosis of gastroenteritis. The nurse would expect the use of which type of fluids initially upon admission?
Isotonic
Hypotonic
Hypertonic
Colloid
The Correct Answer is A
A. Isotonic: Isotonic fluids have a similar osmolarity to extracellular fluid and are often used for volume replacement in clients with fluid volume deficits, such as those with gastroenteritis. Isotonic fluids help to expand intravascular volume without causing significant shifts in fluid and electrolyte balance.
B. Hypotonic: Hypotonic fluids have a lower osmolarity than extracellular fluid and are typically used to rehydrate cells in cases of cellular dehydration. While hypotonic fluids can replenish intracellular volume, they are not typically used as initial replacement fluids for clients with fluid volume deficits, especially if there is risk of exacerbating extracellular fluid deficit.
C. Hypertonic: Hypertonic fluids have a higher osmolarity than extracellular fluid and are often used to expand intravascular volume in specific situations, such as severe hyponatremia or hypovolemic shock. However, they are not typically used as initial replacement fluids for clients with gastroenteritis and fluid volume deficits.
D. Colloid: Colloids are solutions containing large molecules, such as albumin or starches, which remain within the vascular space and exert oncotic pressure to draw fluid into the intravascular compartment. While colloids may be used in some cases of severe volume deficit, they are not typically used as initial replacement fluids for clients with gastroenteritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. "How often do you punish him by giving him a time-out or by using physical discipline?": This response focuses on the mother's disciplinary methods rather than addressing the child's behavior directly. It may come across as judgmental or critical of the mother's parenting approach and does not provide helpful guidance or support.
B. "Physical punishment is not the best way to modify a child's behavior.": This response is appropriate because it addresses the mother's concern about punishment for the child's behavior. It educates the mother about the ineffectiveness and potential harm of physical punishment in modifying behavior. Instead, positive reinforcement, redirection, and open communication are recommended strategies for guiding children's behavior.
C. "It isn't unusual for him to fondle his genitals, as this is part of his exploration of his body.": This response normalizes the child's behavior of touching and playing with his genitals as part of natural childhood development. It reassures the mother that such behavior is common and not necessarily indicative of abnormality or misconduct. Education about normal childhood sexual development can alleviate parental concerns and promote understanding and acceptance.
D. "Constantly touching the genitals indicates a urinary tract infection in a toddler.": This response is incorrect and may unnecessarily alarm the mother. While frequent touching of the genitals could indicate discomfort or irritation associated with a urinary tract infection in a toddler, it is not the case for a 7-year-old child. Additionally, it is essential to avoid making medical diagnoses without proper assessment by a healthcare professional.
E. "Give him a little time, and he'll grow out of it. He's just too young to understand right now." This response acknowledges the child's developmental stage and suggests that the behavior is likely temporary and will naturally resolve as the child matures. It reassures the mother that the behavior is typical for a child of this age and may not require immediate intervention.
Correct Answer is C
Explanation
A. The client should not be asked about religion or spirituality: This option is not appropriate. Religion and spirituality are important aspects of holistic care and should be addressed based on the client's preferences and needs. Avoiding discussions about religion or spirituality based on the client's statement may overlook opportunities for supportive care.
B. The client has abandoned religion due to illness: There is no evidence to suggest that the client has abandoned religion due to illness based solely on the statement provided. Assuming such a conclusion without further assessment would be inappropriate and potentially inaccurate.
C. The client could be interviewed about personal experiences that guide their life: This is the correct interpretation. The client's statement indicates that they identify as spiritual but do not adhere to a specific religious denomination. This suggests that the client may have personal beliefs, values, or experiences that guide their life and worldview. The nurse can explore these aspects through open-ended questions to gain insight into the client's spiritual needs and preferences.
D. The client does not believe in a higher power: There is no indication from the client's statement that they do not believe in a higher power. The statement simply suggests that the client does not affiliate with a specific religious denomination, but it does not necessarily imply atheism or disbelief in a higher power.
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