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
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Related Questions
Correct Answer is D
Explanation
A. Oral penicillin is not a primary treatment for nephrotic syndrome. Antibiotics may be used if there is an associated infection, but they are not central to the management of nephrotic syndrome itself.
B. Labetalol is a medication used for hypertension and would not be specifically indicated for nephrotic syndrome unless hypertension is present.
C. Aggressive intravenous fluid resuscitation is not typically used in nephrotic syndrome; instead, fluid management focuses on balancing fluid intake and output carefully.
D. Prednisone, a corticosteroid, is commonly used to reduce inflammation and proteinuria in nephrotic syndrome. It helps to manage the condition effectively by addressing the underlying inflammation.
Correct Answer is D
Explanation
A. Dry mouth is expected postoperatively, especially if the child is not drinking adequate fluids, but it is not a sign of a complication.
B. Mild to moderate pain is expected after a tonsillectomy and should be managed with analgesics.
C. Dried flecks of blood in oral secretions can be normal immediately after surgery, but active bleeding would be concerning.
D. Frequent swallowing is a sign of possible postoperative bleeding, which is a serious complication that requires immediate evaluation and intervention.
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