What assessment should the nurse make before initiating an IV infusion of dextrose in normal saline solution with 20 mEq KCL per liter for a child hospitalized with dehydration?
Fluid intake
Urine output
Capillary refill
Number of stools
The Correct Answer is B
Choice A reason:
Assessing fluid intake is important in managing dehydration, but it is not the most critical assessment before initiating an IV infusion containing potassium chloride (KCL). Fluid intake provides information about the child’s hydration status but does not directly indicate kidney function. Since potassium can cause hyperkalemia if not properly excreted, monitoring urine output is more crucial.
Choice B reason:
Urine output is the most important assessment before initiating an IV infusion containing potassium chloride (KCL). This is because adequate urine output indicates that the kidneys are functioning properly and can excrete excess potassium. Administering potassium chloride without ensuring proper kidney function can lead to hyperkalemia, a potentially life-threatening condition. Therefore, checking urine output is essential to prevent complications.
Choice C reason:
Capillary refill is a useful assessment for evaluating peripheral perfusion and hydration status. However, it does not provide direct information about kidney function or the body’s ability to excrete potassium. While capillary refill can be part of the overall assessment, it is not the most critical factor before administering an IV infusion with potassium chloride.
Choice D reason:
The number of stools is relevant in assessing dehydration, especially if the child has been experiencing diarrhea. However, like fluid intake, it does not directly indicate kidney function. Monitoring urine output is more important before administering potassium chloride to ensure the kidneys can handle the additional potassium load.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3600"]
Explanation
Step-by-Step Calculation:
Step 1: Determine the amount of ORS needed per kg for moderate dehydration.
- Moderate dehydration requires 100 mL of ORS per kg.
Step 2: Calculate the total amount of ORS needed.
- Child’s weight = 36 kg
- Amount of ORS per kg = 100 mL
Step 3: Multiply the child’s weight by the amount of ORS per kg.
- 36 kg × 100 mL/kg = 3600 mL
Step 4: Convert the total amount of ORS from mL to cups.
- 1 cup = 240 mL
- Total ORS needed = 3600 mL
Step 5: Divide the total ORS needed by the amount of mL in one cup.
- 3600 mL ÷ 240 mL/cup = 15 cups
Summary:
The child will need 3600 mL (or 15 cups) of ORS within 4 hours.
Correct Answer is ["2"]
Explanation
Calculation Steps
Step 1: Determine the total urine output in mL.
- Total urine output = 360 mL
Step 2: Determine the child’s weight in kg.
- Weight = 15 kg
Step 3: Determine the time period in hours.
- Time = 12 hours
Step 4: Calculate the urine output in mL/kg/hour.
- Urine output (mL/kg/hour) = Total urine output ÷ (Weight × Time)
Step 5: Perform the multiplication inside the parentheses first.
- Weight × Time = 15 kg × 12 hours = 180 kg·hours
Step 6: Perform the division.
- Urine output (mL/kg/hour) = 360 mL ÷ 180 kg·hours = 2 mL/kg/hour
Result
The child’s urine output is 2 mL/kg/hour.
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