A nurse is planning care for a child who has severe diarrhea.
Which of the following actions is the nurse’s priority?
Introduce a regular diet
Maintain fluid therapy
Rehydrate
Assess fluid balance
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Introducing a regular diet is not the immediate priority for a child with severe diarrhea. The focus should be on stabilizing the child’s condition before reintroducing regular foods.
Choice B rationale:
Maintaining fluid therapy is important, but it is part of the broader goal of managing fluid balance. It is not the first step in addressing severe diarrhea.
Choice C rationale:
Rehydration is crucial, but it falls under the broader category of assessing and managing fluid balance. Ensuring the child is properly hydrated is part of the overall assessment.
Choice D rationale:
Assessing fluid balance is the priority action. This involves evaluating the child’s hydration status, monitoring for signs of dehydration, and ensuring that fluid therapy is appropriately managed. This step is critical to prevent complications from severe diarrhea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Placing the client in a supine position is not recommended during nasogastric tube insertion. The client should be in an upright position, such as sitting up or in a high Fowler’s position, to facilitate the passage of the tube and reduce the risk of aspiration.
Choice B rationale
Withdrawing the tube if the client gags during insertion is not the correct action. Gagging is a common reaction during nasogastric tube insertion. The nurse should pause and allow the client to rest and swallow. The tube should only be withdrawn if the client is unable to breathe or is extremely distressed.
Choice C rationale
Instructing the client to place his chin to his chest and swallow can facilitate the passage of the tube through the esophagus. This position closes off the trachea and opens the esophagus, reducing the risk of the tube entering the trachea.
Choice D rationale
Measuring the tube for insertion from the tip of the nose to the umbilicus is not the correct method. The correct measurement is from the tip of the nose to the earlobe and then down to the xiphoid process of the sternum.
Correct Answer is A
Explanation
Choice A rationale
Allowing the client to rest in a supine position during feeding should prompt the charge nurse to intervene. The client should be in an upright position during feedings and for an hour afterwards to prevent aspiration.
Choice B rationale
Irrigating the NG tube with tap water after feeding is a standard practice. This helps to keep the tube patent and prevent blockages.
Choice C rationale
Administering the feeding through a syringe barrel by gravity is a common method for giving intermittent tube feedings. This method allows for controlled administration of the feeding.
Choice D rationale
Initiating the feeding after aspirating 50 ml of gastric residual is a standard practice. Checking gastric residual volume before feedings helps to assess gastric emptying and tolerance to the feeding.
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