A nurse is caring for a toddler who has infectious gastroenteritis. Which of the following actions should the nurse take?
Offer the toddler flavored gelatin.
Initiate oral rehydration therapy for the toddler.
Include chicken broth in the toddler's diet.
Feed the toddler the BRAT diet.
The Correct Answer is B
Rationale:
A. Offering flavored gelatin can provide some hydration, but it does not provide sufficient electrolytes necessary for rehydration in gastroenteritis.
B. Initiating oral rehydration therapy for the toddler is essential in treating dehydration caused by infectious gastroenteritis. Oral rehydration solutions contain the right balance of electrolytes and fluids to replenish losses.
C. While chicken broth may provide some fluid and salt, it is not as effective as a specific oral rehydration solution tailored for children with gastroenteritis.
D. The BRAT diet (bananas, rice, applesauce, and toast) is no longer recommended as the primary diet for children with gastroenteritis, as it does not provide adequate nutrition or electrolytes.
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Correct Answer is D
Explanation
Rationale:
A. Providing interpretation services over the telephone is not effective for clients with hearing loss who may benefit more from in-person or visual communication.
B. Exaggerated lip movements can be distracting and may not aid understanding; clear and natural speech is more effective.
C. While providing written materials is helpful, ensuring the client can understand the material is key; using an appropriate reading level is essential but secondary to direct communication strategies.
D. Reducing environmental stimuli helps minimize distractions, making it easier for the client to focus on the nurse's speech or lip movements and improving overall communication.
Correct Answer is C
Explanation
Rationale:
A. Withholding the next dose of warfarin may not be necessary at this point, as the INR is elevated but not critically high. Monitoring is essential, but vitamin K administration is indicated if the INR exceeds therapeutic levels significantly.
B. Withholding the heparin infusion is not appropriate since the aPTT is critically elevated, indicating that the client is at risk for bleeding. Heparin should be adjusted, but not entirely withheld without further evaluation.
C. Preparing to administer vitamin K is appropriate because the INR is elevated (1.8), indicating an increased risk for bleeding. Vitamin K is used to reverse the effects of warfarin.
D. Preparing to administer alteplase (a thrombolytic) is unnecessary and inappropriate in this situation, as the client is already receiving anticoagulation therapy with heparin and warfarin.