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 ["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.
Correct Answer is D
Explanation
Choice A reason:
Monitor your child’s temperature daily: Monitoring temperature is important for children with sickle cell anemia as they are prone to infections. A fever can be an early sign of infection, which can be serious for these children. Normal body temperature for children ranges from 36.5°C to 38°C. However, while monitoring temperature is important, it is not the most critical daily advice compared to ensuring adequate hydration.
Choice B Reason:
Restrict outdoor play to 1 hour per day: Limiting outdoor play is not typically necessary unless the child is experiencing extreme fatigue or pain. Physical activity is generally encouraged to maintain overall health, but it should be balanced with rest and hydration. Therefore, this advice is not as crucial as ensuring the child stays hydrated.
Choice C Reason:
Apply cold compresses when your child expresses pain: Cold compresses are not recommended for managing pain in sickle cell anemia. Instead, warm compresses or heating pads are often suggested to help relieve pain by improving blood flow. Cold can cause vasoconstriction, which may worsen pain and complications.
Choice D Reason:
Offer your child fluids frequently to meet their daily fluid goals: Staying well-hydrated is essential for children with sickle cell anemia. Adequate hydration helps prevent sickle cell crises by reducing blood viscosity and promoting better blood flow. This is the most appropriate and critical advice for daily care.
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