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 D
Explanation
Choice A reason:
Infants do not outgrow clubfoot when they learn to walk. Clubfoot is a congenital deformity that requires medical intervention to correct. Without treatment, the condition can lead to significant disability and difficulty in walking1. The goal of treatment is to correct the foot’s position and function, allowing the child to walk normally.
Choice B reason:
Surgical intervention is not the first line of treatment for clubfoot. While surgery may be necessary in severe cases or if other treatments fail, the initial approach typically involves non-surgical methods. The Ponseti method, which includes serial casting and gentle manipulation, is the preferred initial treatment. Surgery is considered only if these methods do not achieve the desired results.
Choice C reason:
Traction with foot manipulation is not a standard treatment for clubfoot. The primary non-surgical treatment involves the Ponseti method, which includes serial casting and gentle manipulation of the foot3. This method has been shown to be highly effective in correcting clubfoot without the need for traction.
Choice D reason:
Frequent serial casting is the first line of treatment for clubfoot. The Ponseti method, which involves weekly casting and gentle manipulation of the foot, is the most widely used and effective treatment for clubfoot. This method gradually corrects the foot’s position over several weeks, followed by bracing to maintain the correction4. Serial casting is preferred because it is non-invasive and has a high success rate.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason:
Jaundice can be an assessment finding in infants with a urinary tract infection (UTI). UTIs can cause systemic symptoms in infants, including jaundice, especially in newborns. This is due to the immature liver function and the body’s response to infection1. Jaundice in the context of a UTI requires prompt medical evaluation and treatment to prevent complications.
Choice B reason:
Failure to gain weight is another possible assessment finding in infants with a UTI. Infants with UTIs may experience poor feeding, irritability, and lethargy, which can contribute to inadequate weight gain2. Monitoring an infant’s growth and development is crucial, and any signs of failure to thrive should prompt further investigation for underlying conditions such as UTIs.
Choice C reason:
Swelling of the face is not typically associated with UTIs in infants. While facial swelling can be a sign of other medical conditions, it is not a common symptom of UTIs. UTIs primarily affect the urinary system and may cause symptoms such as fever, irritability, and poor feeding.
Choice D reason:
Persistent diaper rash can be an assessment finding in infants with a UTI. The presence of a UTI can lead to increased urine output and changes in urine composition, which can irritate the skin and contribute to diaper rash. Persistent or recurrent diaper rash in conjunction with other symptoms may warrant further evaluation for a UTI.
Choice E reason:
Vomiting is a common symptom in infants with UTIs. The infection can cause gastrointestinal symptoms such as vomiting, diarrhea, and poor feeding. These symptoms, along with fever and irritability, are often seen in infants with UTIs and should prompt medical evaluation.
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