A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)

The correct answer is (C) Determine if the toddler is voiding.

Choice A: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child’s hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children.

Choice B: Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child’s hydration status needs to be assessed.

Choice C: Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child’s hydration status, which is critical in managing acute gastroenteritis.

Choice D: Request evaluation of the toddler’s serum electrolytes Requesting an evaluation of the toddler’s serum electrolytes is also important, but it’s typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child’s hydration status.

Choice A rationale
A child who received a blood transfusion 1 month ago is not recommended to receive the varicella vaccine. This is because blood transfusions can introduce new antibodies into the body that may interfere with the immune response to the vaccine.
Choice B rationale
A child currently receiving immunoglobulins should not receive the varicella vaccine. Immunoglobulins are proteins in the blood that function as antibodies. They can interfere with the body’s immune response to the vaccine.
Choice C rationale
A child currently receiving chemotherapy should not receive the varicella vaccine. Chemotherapy can weaken the immune system, making it less effective at responding to vaccines.
Choice D rationale
A child who has a cold and nasal discharge can receive the varicella vaccine. Mild illnesses, such as a cold, do not interfere with the immune response to the vaccine.