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 D

Explanation

Choice A rationale
Rapid respirations are not typically a manifestation of hypoglycemia. They are more commonly associated with conditions that cause metabolic acidosis, such as diabetic ketoacidosis.
Choice B rationale
Diminished reflexes are not a typical manifestation of hypoglycemia. They may be seen in conditions affecting the nervous system.
Choice C rationale
Acetone breath is not a manifestation of hypoglycemia. It is a sign of ketoacidosis, which is a complication of hyperglycemia, not hypoglycemia.
Choice D rationale
Diaphoresis, or sweating, is a common symptom of hypoglycemia. The body produces sweat as part of the sympathetic nervous system’s response to hypoglycemia.

A. Bradycardia B. Hyperactive bowel sounds C. WBC 17,000/mm D. Left lower quadrant abdominal pain

Correct Answer is C

Explanation

Choice A rationale
Bradycardia, or a slower than normal heart rate, is not typically associated with acute appendicitis. In fact, tachycardia, or a faster than normal heart rate, may occur due to the body’s response to inflammation and infection.
Choice B rationale
Hyperactive bowel sounds are not a typical finding in acute appendicitis. In fact, bowel sounds may be normal or decreased due to the inflammatory process.
Choice C rationale
A white blood cell (WBC) count of 17,000/mm is higher than the normal range, indicating the presence of an infection or inflammation in the body. This is a common finding in acute appendicitis.
Choice D rationale
Pain from appendicitis is typically located in the right lower quadrant of the abdomen, not the left.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

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