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What will be the nurse's priority goal of the infant's care?
- A. Prevent fluid and electrolyte imbalance.
- B. Prevent nutritional deficiency.
- C. Prevent skin breakdown.
- D. Prevent malabsorption.
Correct Answer: A
Rationale: Preventing fluid and electrolyte imbalance is the priority in acute gastroenteritis to avoid life-threatening complications.
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What does the nurse suspect based on this information?
- A. Pinworms
- B. Giardiasis
- C. Ringworm
- D. Roundworm
Correct Answer: A
Rationale: Anal itching and scratching are characteristic symptoms of pinworm infection.
The nurse knows that the child needs to consume how many milliliters of oral fluid to make up for the fluid loss?
- A. 18
- B. 36
- C. 64
- D. 81
Correct Answer: D
Rationale: For an 18-pound (8.1 kg) child, 10 mL/kg yields 81 mL of oral fluid to replace losses from one diarrheal stool.
What sign(s) indicate(s) moderate dehydration?
- A. 10% weight loss
- B. Dry mucous membranes
- C. Normal anterior fontanel
- D. Increased urinary output
- E. Lethargy
Correct Answer: A,B,C
Rationale: Moderate dehydration is characterized by 10% weight loss, dry mucous membranes, and a normal fontanel; urine output decreases, and irritability, not lethargy, is typical.
How does the nurse interpret these values?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: A pH of 7.32 and low HCO3- (21) indicate metabolic acidosis, common in severe dehydration.
What is the most appropriate action?
- A. Induce vomiting by giving the child syrup of ipecac.
- B. Take the child to the local emergency department.
- C. Give the child activated charcoal mixed with juice.
- D. Give the child milk to soothe affected mucous membranes.
Correct Answer: B
Rationale: Taking the child to the emergency department with the ingested substance's packaging is the safest action for dishwashing detergent ingestion.