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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Performing hand hygiene frequently and consistently is the most effective way to prevent the spread of pathogens during patient care. Hand hygiene is the single most important measure to reduce the transmission of harmful germs and prevent health care-associated infections.

Choice B rationale

Properly disposing of contaminated equipment is important in preventing the spread of pathogens, but it is not the most effective measure. While it is crucial to handle and dispose of contaminated equipment properly, hand hygiene is the most effective measure in preventing the spread of pathogens.

Choice C rationale

Discarding used syringes in appropriate containers is a standard safety measure in healthcare settings, but it is not the most effective way to prevent the spread of pathogens during patient care. While it is important for preventing needlestick injuries and the spread of bloodborne pathogens, hand hygiene is the most effective measure in preventing the spread of pathogens.

Choice D rationale

Changing soiled linens daily for patients with draining wounds is a part of standard wound care and infection control, but it is not the most effective way to prevent the spread of pathogens during patient care. Hand hygiene remains the most effective measure in preventing the spread of pathogens.

A. Broth B. Apple juice C. Cherry gelatin D. Pedialyte . E. Pedialyte .

Correct Answer is D

Explanation

Choice A rationale

Broth is a clear liquid that can help replace sodium and chloride lost through diarrhea. However, it does not contain the necessary amounts of other electrolytes such as potassium and bicarbonate, which are also commonly lost in diarrhea.

Choice B rationale

Apple juice is not a good choice for a child with acute diarrhea. It is high in sugars and can worsen diarrhea. It also does not contain the electrolytes needed to replace those lost through diarrhea.

Choice C rationale

Cherry gelatin is not a suitable choice. While it is a clear liquid that can help with hydration, it does not contain the necessary electrolytes to replace those lost through diarrhea. It is also high in sugars, which can worsen diarrhea.

Choice D rationale

Pedialyte is the best choice for a child with acute diarrhea who reports that he is thirsty. It is a rehydration solution specifically designed to replace fluids and electrolytes lost through diarrhea.

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A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a group of assistive personnel (AP) about infection control measures on the unit. Which of the following is the most effective way to prevent the spread of pathogens during patient care?

Correct Answer is A

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

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Correct Answer is D

Explanation

Choice A rationale

Choice C rationale

Choice D rationale

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A nurse is planning care for a child who has severe diarrhea.
Which of the following actions is the nurse’s priority?