A nurse is caring for a 4-year-old who was admitted with acute diarrhea and dehydration. Which finding indicates that oral rehydration therapy has been effective?
Capillary refill greater than 3 seconds
Respiratory rate 24/min
Urine specific gravity 1.015 (nl. 1.005-1.030)
Heart rate 130/bpm
The Correct Answer is C
A. A capillary refill greater than 3 seconds suggests ongoing dehydration and poor perfusion, indicating that oral rehydration has not been fully effective.
B. A respiratory rate of 24/min is within normal limits for a 4-year-old but is not a direct indicator of hydration status.
C. A urine specific gravity of 1.015 is within the normal range, indicating adequate hydration and that oral rehydration therapy has been effective.
D. A heart rate of 130 bpm, while potentially normal for a 4-year-old, does not specifically indicate the effectiveness of rehydration therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Topical corticosteroid ointments are commonly used to reduce inflammation and treat flare-ups in children with eczema. The nurse should instruct the parent on the proper use of these medications.
B. Bubble baths can be irritating to the skin and should be avoided, especially in children with eczema, as they can exacerbate dryness and irritation.
C. The skin should be patted dry rather than rubbed, and moisturizers should be applied while the skin is still slightly damp to help retain moisture.
D. Fabric softeners can be irritating to sensitive skin and are not recommended for laundering the clothing of children with eczema.
Correct Answer is D
Explanation
A. Bronchiolitis usually presents with wheezing and difficulty breathing, not drooling or inability to cough.
B. Asthma typically presents with wheezing, shortness of breath, and coughing, but not with drooling or an inability to cough.
C. Nasopharyngitis, or the common cold, usually causes symptoms like runny nose, cough, and sore throat, but not drooling or agitation.
D. Bacterial epiglottitis is a life-threatening condition characterized by drooling, agitation, inability to cough, and potential airway obstruction. The child often appears anxious and sits leaning forward in a "tripod" position.
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