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ATI Video Series: Nursing Care of Children- Fluid & Electrolyte BalancePediatric Dehydration
RN Fluid & Electrolyte Balance: Dehydration 3.0 Case Study Test
1. A Nurse id providing discharge teaching about oral rehydration to the parent of a
preschooler who has dehydration. Which of the following statements by the parent indicates
an understanding of the teaching?
A. “I will offer my child a cup of oral rehydration fluid every time they have diarrhea.”
B. “I will give my child apple juice in between meals to keep them hydrated.”
C. “I will give my child bananas, rice, applesauce, and toast until their diarrhea subsides.”
D. I will give my child chicken broth three times each day.”
Answer: A. “I will offer my child a cup of oral rehydration fluid every time they have
diarrhea.”
Correct: Stool losses should be replaced on a one-to-one basis by using oral rehydration
fluids to maintain electrolyte balances.
B. “I will give my child apple juice in between meals to keep them hydrated.”
Incorrect: Offering fruit juices, such as apple juice, does not help with diarrhea because they
have high osmolality and contain a large amount of carbohydrates.
C. “I will give my child bananas, rice, applesauce, and toast until their diarrhea subsides.”
Incorrect: The BRAT diet of bananas, rice, applesauce, and toast is contraindicated for
children who have acute diarrhea because the diet little nutritional value.
D. I will give my child chicken broth three times each day.”
Incorrect: Chicken broth and other broths should be avoided because they contain little
nutritional value are high in sodium.
2. A nurse is assessing a 4-year-old child who has severe dehydration. Which of the following
manifestations should the nurse expect?
A. 10% weight loss
B. Respiratory rate of 18/min
C. Capillary refill 3 seconds
D. Urine output 24 mL/hr
Answer: A. 10% weight loss
Correct: The nurse should recognize that a child who has serve dehydration will exhibit a
weight loss of 10% or greater
B. Respiratory rate of 18/min
Incorrect: The nurse should recognize that a child who has serve dehydration will exhibit
hyperpnea, which is deep and rapid respiration.
C. Capillary refill 3 seconds
Incorrect: The nurse should recognize that a child who has serve dehydration will exhibit a
delayed capillary refill of greater than 4 seconds.
D. Urine output 24 mL/hr
Incorrect: The nurse should recognize that a urine output of 24 mL/hr is within the expected
reference range for a 4-year-old child. A child who has serve dehydration will exhibit oliguria
or anuria.
3. A nurse is preparing to administer potassium IV to a preschooler who has dehydration.
Which of the following actions should the nurse plan to take?
A. Administer the medication IV bolus over 5 min.
B. Ensure the child has voided prior to administration.
C. Administration calcium gluconate prior to the medication.
D. Withhold food high in potassium for 24hr following the medication.
Answer: B. Ensure the child has voided prior to administration.
Correct: The nurse should ensure the child has voided prior to the administration of
potassium because potassium is excreted though the urinary system. If a child has renal
impairment, potassium will not be able to leave the body, leading to hyperkalemia.
A. Administer the medication IV bolus over 5 min.
Incorrect: The nurse should administer potassium slowly because a rapid infusion can lead
to cardiac arrest.
C. Administration calcium gluconate prior to the medication.
Incorrect: The nurse should administer calcium gluconate to clients who have hyperkalemia.
D. Withhold food high in potassium for 24hr following the medication.
Incorrect: The nurse should limit foods high in potassium for clients who have
hyperkalemia.
4. A nurse is preparing to obtain a stool specimen from a preschooler to test for the presence
of clostridium difficile. The child is wearing diaper briefs because of recent occurrences of
diarrhea. Which of the following actions should the nurse take?
A. Insert a swab 2.5 cm (1 in) into the rectum for 30 seconds.
B. Place a specimen of two different stools specimens in the container for the test.
C. Put the stool sample in a sterile container before sending it to the laboratory.
D. Place a urinary collection bag on the child before collecting the stool specimen.
Answer: D. Place a urinary collection bag on the child before collecting the stool specimen.
Correct: The nurse should place a urinary collection bag on the child to avoid contaminating
the stool specimen with urine.
A. Insert a swab 2.5 cm (1 in) into the rectum for 30 seconds.
Incorrect: The nurse should not use a swab to obtain a stool specimen for C. difficile
because the swab does not allow enough stool to be collected for accurate results.
B. Place a specimen of two different stools specimens in the container.
Incorrect: The nurse should not combine stool specimens in the same container.
C. Put the stool sample in a sterile container before sending it to the laboratory.
Incorrect: The nurse should place the stool sample in a clean specimen container before
sending to the laboratory.
5. A nurse is caring for a preschooler who has excoriated skin related to diarrhea. Which of
the following actions should the nurse take?
A. Cleanse the area with an alkaline soap during each diaper brief change.
B. Avoid using extra absorbent disposable diaper briefs until the skin has healed.
C. Apply a thin layer of zinc oxide to the affected area during each diaper brief change.
D. Expose the affected area to a heat lamp every 5hr for 10min.
Answer: C. Apply a thin layer of zinc oxide to the affected area during each diaper brief
change.
Correct: The should apply a thin layer of zinc oxide during each diaper brief change to
protect the skin from moisture and further breakdown.
A. Cleanse the area with an alkaline soap during each diaper brief change.
Incorrect: The nurse should cleanse the affected area using a non-alkaline soap and water to
remove fecal material from the skin. The nurse should avoid using alkaline soaps because
they can irritate the skin.
B. Avoid using extra absorbent disposable diaper briefs until the skin has healed.
Incorrect: The nurse should use extra-absorbent disposable diaper briefs to assist with
keeping moisture away from the child’s skin and to prevent further breakdown.
D. Expose the affected area to a heat lamp every 5hr for 10min.
Incorrect: The nurse should expose the affected area to air often as possible to assist with
keeping the area dry. A heat lamp could burn the child.
