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A nurse is assisting with the care of a 2-year-old child.

Which of the following actions should the nurse take when assisting with the implementation of the plan of care? Select all that apply.

Initiate NPO status

Maintain IV fluids.

Maintain strict intake and output.

Weigh the child daily.

Instruct the guardian about proper hand hygiene.

Check the child's temperature rectally.

Monitor laboratory values.

Answer and Explanation

Correct Answer : B,C,D,E,G

A. Initiate NPO status: The child is already unable to tolerate oral intake due to vomiting, but routine NPO status is not always necessary unless prescribed. With mild to moderate dehydration, oral rehydration may be attempted if tolerated, and withholding all fluids could worsen fluid deficit.

B. Maintain IV fluids: The child demonstrates signs of moderate dehydration, including weight loss, sunken eyes, delayed skin turgor, and reduced urine output. IV fluid therapy is necessary to restore intravascular volume, correct electrolyte imbalances, and prevent progression to hypovolemic shock.

C. Maintain strict intake and output: Accurate monitoring of fluid intake and urine/stool output is critical to assess hydration status and guide IV fluid replacement. The child’s ongoing diarrhea and low urine output indicate the need for close tracking to prevent further fluid deficit.

D. Weigh the child daily: Daily weight measurement is an objective and sensitive indicator of hydration status in pediatric clients. The child’s 0.5 kg (1 lb) weight loss over 24 hours reflects significant fluid loss and helps guide ongoing fluid management.

E. Instruct the guardian about proper hand hygiene: The child has a confirmed Escherichia coli infection, which is highly transmissible via the fecal–oral route. Educating the guardian about proper handwashing helps prevent spread to others and reinforces infection control practices.

F. Check the child's temperature rectally: Rectal temperature measurement is invasive and may increase discomfort or risk of injury, especially in a drowsy or irritable toddler. Oral or axillary methods are safer and sufficient for routine monitoring.

G. Monitor laboratory values: Electrolytes, BUN, creatinine, and other relevant labs are crucial to assess the severity of dehydration, renal perfusion, and metabolic disturbances. Trends in these values guide fluid and electrolyte replacement and indicate improvement or deterioration.

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Correct Answer is C

Explanation

A. Pour liquid by holding the bottle with the label facing the sterile field: When pouring solutions onto a sterile field, the label should face the nurse’s hand, not the sterile field. This prevents the liquid from running down the bottle and obscuring or washing off the label, which maintains accurate identification of the solution while protecting the sterile field.

B. Prepare the sterile field 5 cm (2 in) below the level of the waist: The sterile field should be set up at or above waist level to prevent accidental contamination. Positioning it below waist level increases the risk of droplets, contact with nonsterile surfaces, or accidental touches, compromising sterility.

C. Pour liquids from 10 to 15 cm (4 to 6 in) above the sterile field: Maintaining this distance ensures that the fluid is poured without splashing or touching the sterile field with the bottle, which reduces contamination risk. This technique balances control and safety while preserving sterility during preparation or dressing changes.

D. Open the outermost flap of the wrapper toward the body: The outermost flap should be opened away from the body to prevent reaching over the sterile field, which could result in accidental contamination. Opening toward the body increases the chance that clothing or hands might contact the sterile surface.

A. Tachycardia B. Mental alertness C. Hyperreflexia D. Pinpoint pupils

Correct Answer is D

Explanation

A. Tachycardia: Opioid intoxication typically causes bradycardia rather than tachycardia due to central nervous system depression and increased parasympathetic activity. Elevated heart rate is more commonly associated with stimulant use or withdrawal states, not opioid intoxication.

B. Mental alertness: Opioids depress the central nervous system, leading to drowsiness, sedation, or stupor. Mental alertness is not consistent with opioid intoxication; instead, clients often present with decreased responsiveness and impaired cognition.

C. Hyperreflexia: Opioid intoxication generally causes decreased reflexes due to CNS depression. Hyperreflexia is more characteristic of stimulant intoxication or opioid withdrawal, not acute opioid toxicity.

D. Pinpoint pupils: Miosis, or constricted pupils, is a classic sign of opioid intoxication. Opioids stimulate the parasympathetic system via the Edinger-Westphal nucleus, causing the pupils to constrict. This is a reliable clinical indicator of opioid effects and is used in assessment of intoxication.

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A nurse is assisting with the care of a 2-year-old child.

Which of the following actions should the nurse take when assisting with the implementation of the plan of care? Select all that apply.