A nurse is assisting with the care of a school-age child who has shigella. Which of the following actions should the nurse take?
Maintain oral rehydration therapy.
Provide a diet high in sodium.
Administer antiviral medication.
Give antidiarrheal agents every 4 hours.
The Correct Answer is A
Choice A rationale:
Maintaining oral rehydration therapy is a crucial nursing action when caring for a child with shigella, which is a bacterial infection that causes severe diarrhea. Oral rehydration therapy helps prevent dehydration and electrolyte imbalances caused by fluid loss from diarrhea. It involves giving the child oral rehydration solutions containing electrolytes and fluids to replace those lost through diarrhea.
Choice B rationale:
Providing a diet high in sodium is not recommended for a child with shigella. Shigella is associated with diarrhea and gastrointestinal symptoms, and a high-sodium diet can worsen fluid imbalances and dehydration.
Choice C rationale:
Shigella is a bacterial infection, not a viral infection, so administering antiviral medication would not be effective or appropriate. Antiviral medications are used to treat viral infections, not bacterial ones like shigella.
Choice D rationale:
Giving antidiarrheal agents every 4 hours is not recommended for a child with shigella. Antidiarrheal agents can slow down the gastrointestinal tract and inhibit the body's natural mechanism for expelling harmful substances, such as bacteria. It's important to allow the body to eliminate the bacteria and toxins causing the infection through diarrhea, while simultaneously providing rehydration support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The correct answer is choice A. This action is crucial to ensure accurate capillary blood glucose testing. Allowing the skin antiseptic to dry before puncturing the child's finger helps prevent contamination of the blood sample, which can lead to inaccurate results. Wet antiseptic can dilute the blood sample and affect the glucose reading.
Choice B rationale:
This choice is incorrect because placing a cool washcloth on the child's finger is not standard practice before capillary blood glucose testing. While warmth can help increase blood flow and make the puncture process more comfortable, using a cool washcloth is not recommended, as it may constrict blood vessels and make it harder to obtain a sufficient blood sample.
Choice C rationale:
This choice is incorrect because testing the first drop of blood obtained after puncturing the child's finger is not recommended. The first drop of blood can be diluted with interstitial fluid and may not provide an accurate glucose reading. It's important to wipe away the first drop and use the subsequent drop of blood for testing.
Choice D rationale:
This choice is incorrect because puncturing the center of the pad of the child's index finger is not the recommended site for capillary blood glucose testing. The sides of the fingertip contain an adequate blood supply and are less painful for the child. Puncturing the center of the fingertip can be more painful and may not yield a sufficient blood sample.
Correct Answer is B
Explanation
Choice A rationale:
Urine osmolality 500 mOsm/kg. Urine osmolality is a measure of urine concentration and is not a reliable indicator of infection. It reflects the kidney's ability to concentrate urine and can vary based on hydration status and other factors. An elevated urine osmolality could suggest dehydration, not necessarily infection.
Choice B rationale:
WBC 17,500/mm3. This is the correct choice. An elevated white blood cell count (WBC) is a hallmark sign of infection. The body's immune response to an infection often includes an increase in WBC count, particularly the neutrophil count. This elevation is known as leukocytosis and is a red flag for infection.
Choice C rationale:
BUN 12 mg/dL. Blood Urea Nitrogen (BUN) measures kidney function and hydration status. While an elevated BUN can indicate dehydration, it is not a specific marker for infection. BUN levels can be influenced by various factors, including diet and renal function.
Choice D rationale:
Urine specific gravity 1.014. Urine-specific gravity reflects the concentration of solutes in urine and the kidney's ability to concentrate or dilute urine. While changes in urine specific gravity can indicate dehydration or overhydration, it is not a direct indicator of infection. An infection is better detected through changes in WBC count and other clinical signs.
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