A nurse is caring for a dehydrated child and needs to correct electrolyte imbalances as part of the treatment plan.
Which of the following actions should be taken by the nurse?
Administer electrolyte solutions or supplements as prescribed by the physician.
Monitor the child’s response to treatment and adjust the plan accordingly.
Collaborate with physicians, nutritionists, and other healthcare professionals to ensure comprehensive care.
Assess the degree of dehydration based on clinical signs and symptoms.
The Correct Answer is B
Choice A rationale:
Administer electrolyte solutions or supplements as prescribed by the physician.
Rationale: While administering electrolyte solutions or supplements may be part of the treatment plan for a dehydrated child, it is not the initial action that the nurse should take.
The first step should be to assess the child's condition and monitor their response to treatment.
Choice B rationale:
Monitor the child’s response to treatment and adjust the plan accordingly.
Rationale: This is The correct answer.
Dehydration is a complex condition, and the nurse's initial action should be to closely monitor the child's response to treatment, which may include oral or intravenous rehydration.
By monitoring the child's vital signs, urine output, and clinical signs, the nurse can make real-time adjustments to the treatment plan.
Choice C rationale:
Collaborate with physicians, nutritionists, and other healthcare professionals to ensure comprehensive care.
Rationale: Collaboration with other healthcare professionals is important for the overall care of the child, but it is not the immediate action needed to correct electrolyte imbalances in a dehydrated child.
Monitoring and treatment adjustments come first.
Choice D rationale:
Assess the degree of dehydration based on clinical signs and symptoms.
Rationale: While assessing the degree of dehydration is important, it should not be the only action taken.
Monitoring the child's response to treatment and adjusting the plan is equally crucial.
Dehydration assessment is typically part of the initial evaluation, but ongoing monitoring is necessary to ensure the child's condition improves.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Gastrointestinal illnesses, particularly diarrhea and vomiting, lead to fluid loss from the body.
Diarrhea can cause significant loss of water and electrolytes, leading to dehydration.
Vomiting, especially when persistent, can also result in fluid depletion.
These conditions are common causes of dehydration in both children and adults.
Choice B rationale:
Excessive sweating during physical activity or in hot weather can lead to dehydration in individuals, but this scenario does not apply to the child described in the question, who is experiencing decreased urine output and dark-colored urine.
Sweating excessively is more common in older children and adults during physical activities.
Choice C rationale:
Fever, which increases the body's fluid requirements, is a valid point.
However, the child in this scenario does not have fever mentioned as a symptom.
In the absence of fever, gastrointestinal illnesses are the more likely cause of dehydration.
Choice D rationale:
Certain medical conditions, such as diabetes or kidney disease, can lead to chronic dehydration.
However, these conditions are not mentioned in the scenario provided.
In the absence of information about underlying medical conditions, gastrointestinal illnesses remain the most likely cause of the child's dehydration.
Correct Answer is D
Explanation
The correct answer is Choice B: Total maintenance fluids = 1200 mL/day.
Choice A rationale:
This value exceeds the calculated requirement for a child weighing 18 kg using the Holliday-Segar method.
Choice B rationale:
The Holliday-Segar method calculates maintenance fluids based on weight as follows:
- For the first 10 kg, the requirement is 100 mL/kg.
- For the next 10 kg, the requirement is 50 mL/kg.
Thus, for a child weighing 18 kg:
- First 10 kg: 10 kg x 100 mL/kg = 1000 mL
- Next 8 kg: 8 kg x 50 mL/kg = 400 mL Total maintenance fluid requirement = 1000 mL + 400 mL = 1400 mL/day.
So, actually, the correct answer should be Choice D: 1400 mL/day.
Choice C rationale:
This value is higher than the requirement for 18 kg based on the Holliday-Segar method.
Choice D rationale:
This is the correct calculation based on the method described above: 1000 mL for the first 10 kg plus 400 mL for the next 8 kg totals 1400 mL/day.
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