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 ["B","C","E"]
Explanation
Choice A rationale
Spinal defects and sac-like protrusions are not typically associated with muscular dystrophy. They are more commonly seen in conditions like spina bifida.
Choice B rationale
Muscular weakness in the lower extremities is a common symptom of muscular dystrophy. This is due to the progressive degeneration of muscle fibers, which leads to weakness and loss of muscle mass.
Choice C rationale
Kyphosis of the lower spine can be a complication of muscular dystrophy. As the muscles supporting the spine weaken, the spine can curve abnormally, leading to kyphosis.
Choice D rationale
Purposeless, involuntary, abnormal movements are not typically associated with muscular dystrophy. These symptoms are more commonly seen in neurological conditions like Huntington’s disease or certain types of cerebral palsy.
Choice E rationale
An unsteady waddling gait is often seen in individuals with muscular dystrophy. This is due to the progressive weakness and loss of muscle mass in the lower extremities.
Correct Answer is B
Explanation
Choice A rationale
Shingles, also known as herpes zoster, is a viral infection that causes a painful rash and is caused by the varicella-zoster virus, the same virus that causes chickenpox.
Choice B rationale
Tinea pedis is a foot infection due to a dermatophyte fungus. It is the most common dermatophyte infection and is particularly prevalent in hot, tropical, urban environments. Interdigital involvement is most commonly seen (this presentation is also known as athlete’s foot, although some people use the term for any kind of tinea pedis).
Choice C rationale
Fever blister, also known as cold sores, are caused by the herpes simplex virus. They are small, fluid-filled blisters that develop on the lips or around the mouth.
Choice D rationale
Pinworms are a type of parasite that lives in the lower intestine of humans. They are tiny, narrow worms. They are white and less than a half-inch long.
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