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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice B rationale
Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature.
Choice A rationale
Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature.
Choice C rationale
Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed.
Choice D rationale
Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.

A. Gently reinsert the tubes. B. Call the health care clinic to report that the tubes have fallen out. C. Reassure the mother that the tubes will not fall out. D. Take the child to an emergency department.

Correct Answer is B

Explanation

Choice A rationale
It is not advisable for a parent to attempt to reinsert the tubes if they fall out. This could potentially cause harm to the child’s ear.
Choice B rationale
If the tubes fall out, the parent should call the healthcare clinic to report this. The healthcare provider can then decide on the appropriate next steps.
Choice C rationale
It is not accurate to reassure the mother that the tubes will not fall out. Tympanostomy tubes are designed to fall out on their own after a certain period of time.
Choice D rationale
Taking the child to an emergency department is not necessary unless there are signs of infection or other complications.

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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?

Nursing Test Bank

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