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
Explanation
Choice A rationale
Regular blood sugar testing is crucial for managing type 1 diabetes. It helps the child and their caregivers monitor the child’s blood sugar levels and make necessary adjustments to their insulin doses or diet.
Choice B rationale
This statement indicates a need for additional teaching. Even when sick, it’s important for individuals with type 1 diabetes to continue taking their insulin. Illness often causes blood sugar levels to rise, so insulin is still needed.
Choice C rationale
Rotating injection sites can help prevent skin problems, such as lipodystrophy (a lump under the skin caused by the accumulation of extra fat at the site of many subcutaneous injections of insulin). Therefore, this is a correct practice.
Choice D rationale
Physical activity can lower blood sugar levels. Eating a snack before physical activities like playing soccer can help prevent hypoglycemia (low blood sugar). This is a correct understanding of managing physical activity with type 1 diabetes.
Correct Answer is A
Explanation
Choice A rationale
Activated charcoal is often used in the management of poisoning. It works by binding to the poison in the stomach and preventing it from being absorbed into the body14.
Choice B rationale
Osmotic diarrheal agents are not typically used in gastric lavage. These agents work by increasing the amount of water in the intestinal tract, which can stimulate bowel movements14.
Choice C rationale
Syrup of ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended for use in poisoning cases14.
Choice D rationale
0.9% sodium chloride, or normal saline, is a type of fluid that’s often used in medical treatments, but it’s not typically used in gastric lavage for poisoning14.
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