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 "{\"xRanges\":[93.828125,113.828125],\"yRanges\":[223,243]}"
Explanation
A. Lateral aspect: The preferred location for performing a heel stick on a neonate is the lateral (outer) aspect of the heel, avoiding the central area and the arch of the foot. This area contains fewer nerve endings and less tissue, making it safer and less painful for the infant. It also minimizes the risk of injury to the underlying bones, blood vessels, and nerves.
B. Heel: The heel is not recommended as a puncture site because it contains fat, bone, and nerves, and puncturing the heel could cause injury or complications such as osteochondritis (bone infection). This site also carries a higher risk of injury to blood vessels and tendons.
C. Medial aspect: The medial (inner) aspect of the heel is also not recommended because it is near the medial plantar artery and nerves. Puncturing this area could result in damage to these structures, leading to complications. The lateral aspect is a safer, preferred location.
Correct Answer is A
Explanation
A. The new onset of lethargy in a child with endocarditis is a significant concern, as it can indicate worsening infection or complications such as embolism. This child requires urgent assessment to prevent further deterioration.
B. Erythema of the lips in a child with Kawasaki disease is concerning, but this symptom is expected as part of the disease process. However, other signs like fever and conjunctivitis would be more concerning.
C. An increased erythrocyte sedimentation rate (ESR) in a child with rheumatic fever suggests inflammation, but it is not an immediate life-threatening concern like the lethargy in endocarditis.
D. Weak pedal pulses in a toddler with coarctation of the aorta indicate circulatory compromise, but this child may not be in immediate danger as the condition is often diagnosed and managed with interventions like surgery or medication.
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