Midterm ch 25 Flashcards
A nurse is assessing a 2-year-old child who is admitted with dehydration following a gastrointestinal infection. Which of the following findings is most concerning?
A. Dry mouth and lips
B. Reduced urine output
C. Skin turgor returning to normal within 2 seconds
D. Restlessness and irritability
B. Reduced urine output
Rationale: Reduced urine output is a critical sign of dehydration, especially in children, and may indicate more severe dehydration and the need for immediate intervention.
A 4-year-old child with moderate dehydration is being treated in the emergency department. Which of the following interventions is most appropriate for rehydrating the child?
A. Administering intravenous fluids rapidly without reassessing hydration status
B. Restricting oral fluids to prevent vomiting
C. Providing only plain water to rehydrate the child
D. Offering the child small sips of water or oral rehydration solution (ORS) frequently
D. Offering the child small sips of water or oral rehydration solution (ORS) frequently
Rationale: ORS is specifically designed to replace both water and electrolytes lost during dehydration, and frequent small sips are effective in rehydrating without overwhelming the child’s stomach.
A nurse is caring for a 6-month-old infant diagnosed with dehydration from acute gastroenteritis. Which clinical sign would indicate that the infant is experiencing severe dehydration?
A. Decreased urinary output
B. Sunken fontanel
C. Mild irritability
D. Moist mucous membranes
B. Sunken fontanel
Rationale: A sunken fontanel is a classic sign of severe dehydration in infants and indicates a significant loss of fluid volume.
A child with dehydration is being managed with oral rehydration therapy (ORT). Which of the following statements by the parent indicates the need for further teaching?
A. “I should give my child small amounts of oral rehydration solution every 10-15 minutes.”
B. “I can give my child an oral rehydration solution that contains electrolytes, such as Pedialyte.”
C. “If my child vomits, I should immediately give them more fluids.”
D. “I will monitor my child’s hydration status by checking their urine output.”
C. “If my child vomits, I should immediately give them more fluids.”
Rationale: If a child vomits after oral rehydration therapy, fluids should be withheld for 5-10 minutes, then given in small sips. Immediate re-administration could exacerbate vomiting and further dehydrate the child.
A nurse is caring for a child with moderate dehydration. Which of the following clinical signs should the nurse monitor most closely to assess for worsening dehydration?
A. Respiratory rate and pattern
B. Blood pressure
C. Presence of a rash
D. Capillary refill time
D. Capillary refill time
Rationale: Capillary refill time is a reliable indicator of circulatory status and can provide early evidence of worsening dehydration. Prolonged capillary refill time suggests poor perfusion.
A nurse is preparing to administer an intravenous (IV) fluid bolus to a child with severe dehydration. Which of the following is the priority nursing action before administering the IV fluids?
A. Ensure that the child has a patent IV line and appropriate fluid type
B. Obtain a urine sample to assess kidney function
C. Monitor the child’s weight
D. Document the child’s vital signs and hydration status
A. Ensure that the child has a patent IV line and appropriate fluid type
Rationale: Ensuring that the child has a patent IV line and receiving the correct type of fluid is the priority to ensure safe and effective rehydration before administering IV fluids.
A 3-year-old child is admitted with dehydration and vomiting. The nurse suspects that the child is at risk for hypokalemia due to the loss of potassium from vomiting. Which of the following interventions should the nurse anticipate?
A. Administering potassium-rich foods, such as bananas
B. Administering intravenous fluids with potassium supplementation
C. Encouraging the child to drink fruit juice
D. Monitoring the child’s blood glucose levels
B. Administering intravenous fluids with potassium supplementation
Rationale: Hypokalemia is a common electrolyte imbalance associated with dehydration and vomiting. Potassium supplementation is needed to prevent complications, and it is often given with IV fluids in cases of severe dehydration.
A nurse is assessing a 10-month-old infant for signs of dehydration. Which of the following findings would be most concerning for the nurse?
A. Slightly dry skin and a slightly decreased appetite
B. Slightly increased heart rate and fever
C. A 10% decrease in body weight and a weak cry
D. Normal skin turgor and moist mucous membranes
C. A 10% decrease in body weight and a weak cry
Rationale: A 10% decrease in body weight is a critical sign of dehydration in infants, and a weak cry indicates poor hydration status, which requires urgent intervention.
A nurse is caring for a child with dehydration and is providing parental education. Which of the following instructions is most appropriate?
A. “You can give your child water and juice to rehydrate them.”
B. “Offer your child small amounts of an oral rehydration solution (ORS) frequently.”
C. “Only offer your child clear fluids such as soda or clear broth.”
D. “Avoid offering your child any fluids until they are no longer vomiting.”
B. “Offer your child small amounts of an oral rehydration solution (ORS) frequently.”
Rationale: ORS is designed to replace lost fluids and electrolytes and is the preferred method of rehydration. Small amounts should be given frequently to avoid overwhelming the stomach.
A nurse is caring for a 5-year-old child with dehydration secondary to diarrhea. Which of the following is the priority nursing intervention?
A. Administering antibiotics to prevent infection
B. Starting an IV line for rapid fluid resuscitation
C. Encouraging the child to eat solid foods as soon as possible
D. Monitoring for signs of electrolyte imbalances
D. Monitoring for signs of electrolyte imbalances
Rationale: Dehydration secondary to diarrhea can lead to significant electrolyte imbalances, such as hypokalemia and hyponatremia. Monitoring for these imbalances is a priority before other interventions.
A nurse is caring for a 2-year-old child diagnosed with gastroenteritis. The child has been experiencing frequent watery stools and mild irritability. Which of the following interventions should the nurse implement first?
A. Administer intravenous fluids to correct fluid imbalance
B. Start oral rehydration therapy (ORT)
C. Provide an antiemetic medication
D. Administer an antidiarrheal medication
B. Start oral rehydration therapy (ORT)
Rationale: For mild to moderate dehydration, oral rehydration therapy is the first line of treatment to replace lost fluids and electrolytes. IV fluids are reserved for severe dehydration.
A nurse is educating the parents of a child with gastroenteritis about the importance of rehydration. Which statement by the parent indicates the need for further teaching?
A. “I will offer my child small sips of oral rehydration solution every 10-15 minutes.”
B. “I should avoid giving my child carbonated beverages and fruit juices.”
C. “I can give my child regular milk to drink while they recover.”
D. “I will monitor my child’s urine output to ensure they are staying hydrated.”
C. “I can give my child regular milk to drink while they recover.”
Rationale: Regular milk should not be given during gastroenteritis as it can worsen diarrhea. Oral rehydration solutions are preferred, and the child should be given clear liquids initially.
A 6-month-old infant is hospitalized for severe dehydration due to gastroenteritis. Which finding is most concerning and indicates the need for urgent intervention?
A. Dry mouth and sunken fontanel
B. Mild irritability and increased thirst
C. Normal urine output and alertness
D. Slightly increased heart rate and low-grade fever
A. Dry mouth and sunken fontanel
Rationale: A sunken fontanel and dry mouth are signs of severe dehydration in infants. Immediate intervention is needed to restore hydration.
A child with gastroenteritis is receiving intravenous fluids for severe dehydration. The nurse notes that the child’s urine output has decreased significantly over the past few hours. What is the priority nursing action?
A. Increase the rate of IV fluids
B. Assess vital signs and reassess hydration status
C. Notify the healthcare provider to order an antibiotic
D. Administer a dose of diuretics to promote urine output
B. Assess vital signs and reassess hydration status
Rationale: Decreased urine output can indicate worsening dehydration or renal compromise. It is crucial to reassess the child’s hydration and monitor vital signs closely.
A child with gastroenteritis is being treated with oral rehydration therapy (ORT). Which of the following should the nurse include in the plan of care?
A. Provide large amounts of water to the child to quickly rehydrate
B. Limit oral rehydration solution to 1-2 sips every hour
C. Encourage the child to drink small amounts of oral rehydration solution every 10-15 minutes
D. Withhold oral fluids until the child is no longer vomiting
C. Encourage the child to drink small amounts of oral rehydration solution every 10-15 minutes
Rationale: Small, frequent sips of oral rehydration solution help replace lost fluids and electrolytes without overwhelming the child’s stomach.
A nurse is caring for a child with viral gastroenteritis. The child has had 5 episodes of vomiting and 6 watery stools within the past 24 hours. Which of the following clinical findings would suggest the child is at risk for hypovolemic shock?
A. Decreased heart rate and normal blood pressure
B. Decreased blood pressure and rapid, weak pulse
C. Increased urine output and irritability
D. Elevated temperature and warm, dry skin
B. Decreased blood pressure and rapid, weak pulse
Rationale: Decreased blood pressure and a rapid, weak pulse are signs of hypovolemic shock, which can occur if fluid and electrolyte losses from gastroenteritis are not addressed promptly.
A nurse is caring for a child with gastroenteritis who is receiving oral rehydration therapy. Which of the following should the nurse avoid administering to the child?
A. Oral rehydration solution (ORS)
B. Clear liquids such as broth
C. Fruit juices such as apple juice
D. Small amounts of water
C. Fruit juices such as apple juice
Rationale: Fruit juices should be avoided in gastroenteritis because they can increase the osmotic load in the intestines, worsening diarrhea and abdominal discomfort.
A nurse is explaining to the parents of a child with gastroenteritis that antimicrobial therapy may be prescribed if the diarrhea is caused by a bacterial infection. Which of the following would be an appropriate indication for antimicrobial therapy?
A. Watery diarrhea caused by rotavirus
B. Diarrhea accompanied by a fever over 100.4°F (38°C)
C. Diarrhea associated with lactose intolerance
D. Diarrhea caused by Escherichia coli infection
D. Diarrhea caused by Escherichia coli infection
Rationale: Antimicrobial therapy is indicated for bacterial infections such as those caused by Escherichia coli, but not for viral causes like rotavirus or lactose intolerance.
A 4-year-old child is admitted with gastroenteritis. The child is experiencing mild dehydration and the nurse is planning to initiate oral rehydration therapy (ORT). Which of the following actions is appropriate for the nurse to take?
A. Administer large amounts of water immediately to rehydrate the child
B. Start the child on clear liquids and then advance to regular foods
C. Provide oral rehydration solution in small, frequent sips
D. Withhold all fluids until the child stops vomiting
C. Provide oral rehydration solution in small, frequent sips
Rationale: Oral rehydration solution should be given in small, frequent sips to replace fluids and electrolytes effectively without overwhelming the child’s stomach.
A nurse is caring for an infant diagnosed with gastroenteritis. Which of the following findings is most suggestive of severe dehydration and requires immediate intervention?
A. The infant’s fontanel is sunken, and their skin is cool and clammy
B. The infant has a normal heart rate and normal skin turgor
C. The infant’s urine output is slightly decreased and they are slightly irritable
D. The infant is feeding normally and has moist mucous membranes
A. The infant’s fontanel is sunken, and their skin is cool and clammy
Rationale: A sunken fontanel and cool, clammy skin are signs of severe dehydration in infants and require immediate intervention to prevent further complications.
A nurse is caring for a child with gastroenteritis and is monitoring the child’s stool. The nurse notes that the stool is watery and foul-smelling, and the child has a fever. What should the nurse do next?
A. Administer an antidiarrheal medication to reduce stool frequency
B. Isolate the child to prevent the spread of infection
C. Encourage the child to drink fruit juices to restore hydration
D. Administer intravenous fluids immediately
B. Isolate the child to prevent the spread of infection
Rationale: Isolation is important to prevent transmission of infectious agents, especially when the child has diarrhea and a fever. The stool’s appearance and the fever suggest an infectious etiology.
Which of the following actions should the nurse take when assessing the child’s hydration status? (Select all that apply.)
A. Assess the child’s skin turgor
B. Weigh the child daily and compare to preadmission weight
C. Document the frequency and consistency of stools
D. Encourage the child to drink large amounts of water
E. Monitor the child’s mucous membranes for signs of dryness
A. Assess the child’s skin turgor
B. Weigh the child daily and compare to preadmission weight
C. Document the frequency and consistency of stools
E. Monitor the child’s mucous membranes for signs of dryness
Rationale: Assessing skin turgor, weighing the child daily, documenting stool characteristics, and monitoring mucous membranes are essential for evaluating hydration status. Encouraging large amounts of water is not appropriate for children with gastroenteritis, as it can exacerbate vomiting.
A 4-year-old child with gastroenteritis has been vomiting and having diarrhea for 24 hours. The nurse observes that the child has dry mucous membranes, sunken eyes, and a rapid heart rate. What is the most likely cause of these symptoms?
A. An allergic reaction to food
B. Gastrointestinal bleeding
C. Acute appendicitis
D. Severe dehydration
D. Severe dehydration
Rationale: The dry mucous membranes, sunken eyes, and rapid heart rate are signs of severe dehydration, which can result from fluid losses due to vomiting and diarrhea.
A nurse is caring for an infant with gastroenteritis and is planning to prevent skin breakdown. Which of the following actions should the nurse include in the care plan? (Select all that apply.)
A. Change the infant’s diaper every 2 hours
B. Apply A&D ointment with each diaper change
C. Use a mild soap to clean the diaper area after soiling
D. Leave the infant’s buttocks open to air several times a day
E. Allow the infant to wear underwear if tolerated
A. Change the infant’s diaper every 2 hours
B. Apply A&D ointment with each diaper change
C. Use a mild soap to clean the diaper area after soiling
D. Leave the infant’s buttocks open to air several times a day
Rationale: Frequent diaper changes, application of barrier ointment, and allowing the buttocks to air out are important in preventing and managing skin breakdown. Mild soap is appropriate for cleaning the area, and underwear should be avoided to reduce friction and moisture.
A nurse is caring for a 2-year-old child who is being treated for gastroenteritis. The child has been vomiting and having diarrhea for the past 12 hours, and the nurse is concerned about dehydration. What should the nurse monitor to assess the child’s fluid status?
A. Temperature and pulse rate
B. Urine output and weight
C. Respiratory rate and blood pressure
D. Heart rate and oxygen saturation
B. Urine output and weight
Rationale: Monitoring urine output and weight helps assess the child’s hydration status and fluid balance. A decrease in urine output and significant weight loss are key indicators of dehydration.
A nurse is preparing to administer oral rehydration therapy (ORT) to a child with gastroenteritis. Which of the following is the most appropriate action for the nurse to take?
A. Give the child large amounts of water all at once
B. Encourage the child to drink fruit juice to restore electrolytes
C. Offer the child small sips of oral rehydration solution every 10-15 minutes
D. Withhold fluids until vomiting stops completely
C. Offer the child small sips of oral rehydration solution every 10-15 minutes
Rationale: Offering small, frequent sips of oral rehydration solution helps to replace fluids and electrolytes without overwhelming the child’s stomach, especially when vomiting is present.
A 5-year-old child presents to the emergency department with vomiting for the past 24 hours. The nurse observes that the child has dry mucous membranes, a rapid heart rate, and sunken eyes. What is the most appropriate initial intervention?
A. Administer an antiemetic medication
B. Start intravenous (IV) fluid resuscitation
C. Provide oral rehydration solution
D. Perform an abdominal ultrasound
B. Start intravenous (IV) fluid resuscitation
Rationale: The child’s symptoms are indicative of dehydration, and IV fluid resuscitation is the most appropriate initial intervention to restore hydration and correct electrolyte imbalances. Oral rehydration may not be effective due to the vomiting.
A nurse is caring for a child with vomiting secondary to gastroenteritis. Which of the following interventions is most appropriate for preventing further fluid and electrolyte imbalance?
A. Offer small sips of clear fluids every 5 to 10 minutes
B. Withhold all fluids for 12 hours to allow the gastrointestinal system to rest
C. Encourage the child to drink large amounts of water quickly
D. Administer antiemetic medications before offering fluids
A. Offer small sips of clear fluids every 5 to 10 minutes
Rationale: Small, frequent sips of clear fluids help prevent dehydration while minimizing the risk of vomiting. Large amounts of fluid can overwhelm the stomach and lead to more vomiting.
A nurse is caring for a child with vomiting and dehydration. The child is irritable and has decreased urine output. The nurse suspects the child is in the early stages of dehydration. What should the nurse assess next?
A. Capillary refill and skin turgor
B. Blood pressure and heart rate
C. Weight and temperature
D. Bowel sounds and abdominal girth
A. Capillary refill and skin turgor
Rationale: Capillary refill and skin turgor are key indicators of hydration status. In early dehydration, these signs may be abnormal and help the nurse assess the severity of fluid loss.
A 3-year-old child with vomiting and diarrhea has been unable to retain oral fluids for several hours. The healthcare provider prescribes intravenous fluids for rehydration. Which of the following fluids is most appropriate for initial rehydration?
A. Dextrose 5% in water (D5W)
B. Normal saline (0.9% NaCl)
C. Hypertonic saline (3% NaCl)
D. Lactated Ringer’s solution
D. Lactated Ringer’s solution
Rationale: Lactated Ringer’s solution is the preferred IV fluid for rehydration in children with vomiting and diarrhea, as it contains electrolytes and helps to restore fluid and electrolyte balance. Normal saline could also be used in some cases, but Lactated Ringer’s is often preferred for rehydration.
A nurse is educating the parents of a child who is experiencing vomiting due to gastroenteritis. Which of the following statements by the parents indicates a need for further education?
A. “I should start giving my child small amounts of oral rehydration solution every 10 minutes.”
B. “I should avoid giving my child sugary drinks like soda during this time.”
C. “I will wait until my child is no longer vomiting before offering any fluids.”
D. “I will notify the doctor if my child has a fever or the vomiting worsens.”
C. “I will wait until my child is no longer vomiting before offering any fluids.”
Rationale: It is important to begin offering fluids as soon as vomiting decreases, even if the child has not fully stopped vomiting. Withholding fluids may worsen dehydration and slow recovery.
A 2-year-old child with vomiting and dehydration is receiving intravenous fluids as prescribed. The nurse monitors the child for signs of overhydration. Which of the following findings would indicate fluid overload?
A. Decreased urine output
B. Increased heart rate
C. Dry mucous membranes
D. Edema and respiratory distress
D. Edema and respiratory distress
Rationale: Edema and respiratory distress are signs of fluid overload. These symptoms may indicate that the child has received too much fluid too quickly, overwhelming the circulatory system.
A 9-year-old child presents to the emergency department with right lower quadrant pain, fever, and nausea. The nurse suspects appendicitis. Which of the following signs is most indicative of a ruptured appendix?
A. Decreased abdominal pain after the child moves
B. Relief of pain with flexion of the legs
C. Sudden, severe pain followed by a decrease in pain intensity
D. Pain localized to the epigastric region
C. Sudden, severe pain followed by a decrease in pain intensity
Rationale: A sudden relief of pain after intense abdominal pain is a classic sign of a ruptured appendix, as the rupture can temporarily reduce the pressure and pain. However, this can quickly be followed by the onset of peritonitis.
A 10-year-old child is diagnosed with appendicitis. The nurse is preparing the child for surgery. Which of the following interventions is most important in the preoperative phase?
A. Administering prescribed antibiotics
B. Encouraging oral fluids to maintain hydration
C. Performing an abdominal assessment for rebound tenderness
D. Providing emotional support and reassurance
A. Administering prescribed antibiotics
Rationale: Antibiotics are typically administered preoperatively to prevent infection, especially if there is a risk of perforation or peritonitis. Fluid intake and emotional support are also important but secondary to infection prevention.
A child with appendicitis is admitted to the hospital for observation. Which of the following is the most critical nursing intervention during the acute phase of appendicitis?
A. Monitoring for signs of peritonitis
B. Administering pain medication as prescribed
C. Encouraging the child to ambulate early
D. Restricting oral intake until surgery
A. Monitoring for signs of peritonitis
Rationale: Peritonitis is a life-threatening complication of appendicitis, particularly if the appendix ruptures. Monitoring for symptoms such as fever, tachycardia, and rigid abdomen is critical in the acute phase.
The nurse is caring for a 6-year-old child who had an appendectomy 24 hours ago. The child is complaining of severe abdominal pain and has a distended abdomen. Which of the following actions should the nurse take first?
A. Administer the prescribed pain medication
B. Check the child’s vital signs
C. Assess the child’s incision site for signs of infection
D. Notify the healthcare provider
B. Check the child’s vital signs
Rationale: Abdominal distention and severe pain may indicate complications such as infection, bowel obstruction, or peritonitis. Checking vital signs, including temperature and blood pressure, is critical to assess for signs of infection or sepsis.
A nurse is educating the parents of a child recovering from appendectomy about signs of infection. Which of the following should the nurse include in the teaching?
A. “Expect some swelling around the incision site, which should resolve in a few days.”
B. “The child may experience some mild nausea for up to two weeks after surgery.”
C. “Contact the doctor immediately if you notice a fever over 100.4°F (38°C).”
D. “Pain should improve after 24 hours, but if it worsens, it is likely normal.”
C. “Contact the doctor immediately if you notice a fever over 100.4°F (38°C).”
Rationale: A fever over 100.4°F may indicate infection, such as wound infection or peritonitis, and requires immediate medical attention. Mild nausea and temporary swelling are not uncommon after surgery.
A 12-year-old child is admitted with suspected appendicitis. The nurse performs an assessment and notes tenderness at McBurney’s point. Which of the following is the nurse’s most appropriate action?
A. Administer pain medication and notify the healthcare provider
B. Assess for rebound tenderness and monitor for fever
C. Encourage the child to ambulate to help relieve discomfort
D. Immediately prepare the child for surgery
B. Assess for rebound tenderness and monitor for fever
Rationale: McBurney’s point tenderness is a classic sign of appendicitis. Assessing for rebound tenderness and monitoring for fever helps evaluate the severity and progression of the condition before surgical intervention.
