Safe, Effective Care Environment
37. A nurse is caring for an infant with acute gastroenteritis with an estimated 10% weight loss. Which actions should the nurse take when caring for this infant? Select all that apply.
Safe, Effective Care Environment
37. A nurse is caring for an infant with acute gastroenteritis with an estimated 10% weight loss. Which actions should the nurse take when caring for this infant? Select all that apply.
. Administer IV fluid bolus of 5 mL/kg.
. Apply antibacterial hand foam.
. Put on gloves and gown.
. Administer IV antibiotic.
. Monitor hourly urine output.
. Initiate IV therapy.
Test-Taking Tip
Answers 2 and 3 go together (nurse's self-protection). Answers 5 and 6 go together (give fluid, monitor output).
Content Area: Child Health, Gastrointestinal; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Safety and Infection Control/Standard/Transmission-based/Other Precautions
Safe, Effective Care Environment
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Answer 1 is incorrect because an appropriate fluid bolus for a child with severe dehydration is 20 mL/kg. Answer 2 is correct because the nurse should first clean the hands for infection prevention. Answer 3 is correct because the nurse should wear personal protective equipment for enteric precautions after cleaning hands. Answer 4 is incorrect because acute gastroenteritis is typically caused by a viral illness such as rotavirus, not bacterial illness. Antibiotics would be administered for bacterial, not viral, infection. Answer 5 is correct because the child's urinary output should be monitored frequently to determine the response to treatment. Answer 6 is correct because, once the nurse is protected, IV fluids should be administered to correct the severe dehydration.