A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
Initiate isotonic fluids with 20 mEq/L potassium chloride.
Collect a stool sample from the toddler.
Determine if the toddler is voiding.
Request evaluation of the toddler’s serum electrolytes.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine.
Choice B rationale
Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice C rationale
Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting.
Choice D rationale
While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
Correct Answer is A
Explanation
Choice A rationale
The goal of surgery for Hirschsprung disease is to remove the diseased section of the intestine and then pull the healthy portion of this organ down to the anus. This is typically achieved through a type of surgery called a pull-through procedure. In some cases, doctors recommend ostomy surgery of the bowel followed by a pull-through procedure. During ostomy surgery, surgeons create a stoma on a child’s abdomen and connect the stoma to the large or small intestine. After ostomy surgery, waste will leave the child’s body through the stoma. The stoma is usually temporary. In most cases, surgeons can later close the stoma and connect the healthy part of the intestine to the anus. Waste will move through the intestines, and stool will pass through the anus again. Therefore, the statement “I’m glad that the ostomy is only temporary” indicates understanding of the surgery’s goal.
Choice B rationale
The operation for Hirschsprung’s disease does not involve straightening out a kink in the intestine. Instead, it involves removing the part of the large intestine that is missing nerve cells and then connecting the healthy part of the large intestine to the anus.
Choice C rationale
The use of a feeding tube is not typically associated with the initial surgery for Hirschsprung’s disease. The surgery involves removing the diseased section of the intestine and then pulling the healthy portion of this organ down to the anus.
Choice D rationale
While the ultimate goal of the surgery is to enable normal bowel movements, it is important to note that about half of children may have ongoing problems after surgery. These problems may include constipation and, in some cases, other symptoms of intestinal obstruction, such as a swollen abdomen or vomiting.
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