A nurse is caring for a child who has had diarrhea for 3 days. Which of the following actions should the nurse take?
Weigh the child weekly.
Keep the child NPO for the next 12 hr.
Collect a stool culture.
Offer the child 120 mL (4 oz) of apple juice every 2 hr.
The Correct Answer is C
A. Weighing the child weekly is not an appropriate intervention for managing acute diarrhea, as it does not address the immediate concern of dehydration or infection.
B. Keeping the child NPO for 12 hours is generally not recommended unless the child is severely dehydrated or vomiting, as it could lead to further dehydration. Hydration and appropriate refeeding are important in managing diarrhea.
C. A stool culture can help determine the cause of diarrhea (such as bacterial infection) and guide appropriate treatment. This is a priority in determining the underlying cause of the child's symptoms.
D. Offering apple juice is not recommended for diarrhea, as high fructose content can worsen diarrhea. Oral rehydration solutions (ORS) or clear fluids are more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A 2-year-old toddler should have more than six teeth by this age, and the eruption of only six teeth is a delay in expected development. Most children have 16 teeth by age 2.
B. Using two- or three-word phrases is appropriate for a 2-year-old and is a sign of normal language development.
C. Building a tower of six to seven cubes is an appropriate developmental milestone for a 2-year-old and indicates normal motor development.
D. Being able to pick up objects without falling is a normal gross motor skill for a 2-year-old.
Correct Answer is A
Explanation
A.This is the best action for the nurse to take. Continuous monitoring increases the risk of skin breakdown and pressure necrosis at the sensor site. Rotating the probe site every 2 to 4 hours ensures that the underlying tissue receives adequate circulation and prevents thermal or mechanical injury to the skin.
B. Taping the wire to the palm of the hand is not recommended because it may cause skin irritation or pressure injury. The sensor should be placed on a finger or toe, where blood flow is easily accessible.
C. Applying the sensor to the index fingernail is not ideal. Pulse oximetry is most accurate when applied to a finger or toe, but not directly on the nail itself. It should be placed on the skin near the nail.
D. While adequate perfusion is necessary for an accurate reading, warming the skin is not a routine requirement for probe placement. If a child has poor peripheral circulation (cold extremities), a different site with better perfusion, such as the earlobe or forehead, should be chosen rather than attempting to warm the skin, which could lead to accidental burns if a heat source is used improperly.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.