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:
Weighing the infant every day on the same scale at the same time is crucial in monitoring excess fluid volume in congestive heart failure. Sudden weight gain can indicate fluid retention, a common sign of worsening heart failure. Daily weight monitoring helps in early detection and timely intervention.
Choice B rationale:
Notifying the physician when weight gain exceeds more than 20 g/day might be too late for intervention. Daily weight monitoring is essential to detect trends and intervene promptly to manage excess fluid volume.
Choice C rationale:
Placing the infant in a car seat to minimize movement is not directly related to managing excess fluid volume in congestive heart failure. It is essential for safety during transportation but does not address the nursing diagnosis.
Choice D rationale:
Administering digoxin as ordered by the physician is a medical intervention for congestive heart failure. While important, the nursing diagnosis is related to excess fluid volume, and the focus should be on nursing interventions such as monitoring daily weights.
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.
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