A nurse is assessing a school-age child who is receiving IV fluids to treat dehydration. Which of the following findings should indicate to the nurse that the fluid replacement therapy has been effective?

Capillary refill less than 2 seconds

Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)

Voiding less than 1 mL/kg/hr

Tachycardia

Answer and Explanation

The Correct Answer is A

A. "Capillary refill less than 2 seconds." A capillary refill time of less than 2 seconds indicates adequate hydration and perfusion, showing that the fluid replacement therapy has been effective.

B. "Potassium 5.6 mEq/L (3.4 to 4.7 mEq/L)." A potassium level of 5.6 mEq/L is elevated (hyperkalemia) and suggests an imbalance, which can result from inadequate kidney function or excessive potassium intake rather than effective rehydration.

C. "Voiding less than 1 mL/kg/hr." Decreased urine output is a sign of persistent dehydration or kidney dysfunction. Effective fluid therapy should restore normal urine output, typically greater than 1 mL/kg/hr in children.

D. "Tachycardia." Tachycardia is a sign of dehydration. If fluid replacement were effective, heart rate should normalize, not remain elevated.

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Correct Answer is A

Explanation

A. Obtain a blood culture. The first action is to obtain a blood culture to identify the causative organism before starting antibiotic therapy. This ensures that the appropriate antibiotic is selected.
B. Request a referral for physical therapy. Physical therapy may be needed later, but it is not the priority during admission.
C. Administer IV antibiotics. Antibiotics should be given after obtaining a blood culture to avoid altering the test results.
D. Record intake and output. While monitoring fluid balance is important, it is not the priority action during admission.

A. Heart rate B. HbA1c C. WBC count D. Oxygen saturation

Correct Answer is B

Explanation

A. Heart rate – No data regarding heart rate is provided in the exhibit, so this is not a relevant option.
B. HbA1c – The child's HbA1c level is 8.5%, which is elevated above the normal range (4% to 5.9%). This indicates poor glycemic control, suggesting the development of cystic fibrosis-related diabetes (CFRD), a common complication of cystic fibrosis. This should be reported to the provider for further evaluation and management.
C. WBC count – The WBC count is 9,600/mm³, which is within the normal range (5,000 to 10,000/mm³), so it does not require reporting.
D. Oxygen saturation – No data regarding oxygen saturation is provided in the exhibit, making this option irrelevant.

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A nurse is assessing a school-age child who is receiving IV fluids to treat dehydration. Which of the following findings should indicate to the nurse that the fluid replacement therapy has been effective?

Nursing Test Bank

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