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
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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Related Questions
Correct Answer is B
Explanation
A. "Offer your child foods that are low in calories." Children with cystic fibrosis (CF) require a high-calorie diet because their bodies have difficulty absorbing nutrients due to pancreatic insufficiency.
B. "Offer your child foods that are high in fat." A high-fat diet (35%-40% of total calories from fat) is recommended because fat malabsorption is common in CF, and they need additional fat to meet their energy needs.
C. "Offer your child foods that are high in vitamin C." While vitamin C is important, fat-soluble vitamins (A, D, E, and K) are the primary concern since CF patients struggle to absorb them.
D. "Offer your child foods that are low in protein." Children with CF require adequate protein intake to support growth and maintain muscle mass, so protein restriction is not recommended.
Correct Answer is D
Explanation
A. "Decreased respiratory rate." Moderate dehydration typically causes tachypnea (increased respiratory rate), not a decreased respiratory rate. This is the body's response to metabolic acidosis caused by fluid loss.
B. "Bulging anterior fontanel." A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. Dehydration typically causes a sunken fontanel due to fluid loss.
C. "Mottled skin." Mottled skin can be a sign of severe dehydration or shock, but it is not a definitive indicator of moderate dehydration.
D. "Capillary refill 3 seconds." A capillary refill time of 2–3 seconds is indicative of moderate dehydration. In severe dehydration, capillary refill would be greater than 4 seconds.
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