A nurse is caring for a child who has been admitted with severe dehydration.
The nurse understands that the child’s degree of dehydration is typically classified based on the loss of body weight.
The nurse observes dry mucous membranes, decreased urine output, and decreased skin turgor in the child.
Based on these observations, the nurse should classify the child’s dehydration as:.
“Mild dehydration, which is 3-5% loss of body weight.”.
“Moderate dehydration, which is 6-9% loss of body weight.”.
“Severe dehydration, which is ≥10% loss of body weight.”.
“No dehydration, which is less than 3% loss of body weight.”..
The Correct Answer is C
“Severe dehydration, which is ≥10% loss of body weight.”.
Choice A rationale:
Mild dehydration is typically classified as a 3-5% loss of body weight.
The signs and symptoms described in the scenario, such as dry mucous membranes, decreased urine output, and decreased skin turgor, are indicative of more severe dehydration than a 3-5% loss.
Choice B rationale:
Moderate dehydration is generally considered to be a 6-9% loss of body weight.
However, the signs and symptoms presented in the scenario suggest a more severe state of dehydration.
Choice C rationale:
Severe dehydration is classified as a loss of ≥10% of body weight.
The signs and symptoms observed by the nurse, including dry mucous membranes, decreased urine output, and decreased skin turgor, are consistent with severe dehydration, making choice C The correct classification.
Choice D rationale:
No dehydration is defined as less than a 3% loss of body weight.
The clinical manifestations observed in the child, as described in the scenario, clearly indicate dehydration.
In this case, the child's signs and symptoms align with the classification of severe dehydration, which is characterized by a loss of ≥10% of body weight.
These symptoms include dry mucous membranes, decreased urine output, and decreased skin turgor.
It's crucial to recognize the severity of dehydration accurately to initiate the appropriate treatment and prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Lactated Ringer's solution is not contraindicated in cases of hyperkalemia.
This solution contains potassium in a relatively low concentration of 4 mEq/L, which is unlikely to significantly impact hyperkalemia.
Choice B rationale:
Lactated Ringer's solution can be contraindicated in cases of hypokalemia.
While it does contain potassium, the concentration is relatively low at 4 mEq/L.
In cases of severe hypokalemia, a more potassium-rich solution might be preferred.
Choice C rationale:
Lactated Ringer's solution can be used in cases of lower GI fluid loss.
It can help replace lost fluids and electrolytes effectively.
Choice D rationale:
Lactated Ringer's solution can be used in cases of upper GI fluid loss.
It helps restore lost fluids and electrolytes.
Choice E rationale:
Lactated Ringer's solution is not contraindicated in cases of lactic acidosis.
In fact, it contains lactate (28 mEq/L), which can be metabolized to bicarbonate and help correct acidosis.
Correct Answer is A
Explanation
Choice A rationale:
“This fluid will help to restore my sodium levels and replace the fluids I lost from vomiting.”.
The client should understand that they are receiving Half Normal Saline (0.45% NaCl) to restore sodium levels and replace lost fluids due to vomiting.
Half Normal Saline contains 77 mEq/L of sodium and 77 mEq/L of chloride, making it a suitable choice for a patient with mild hyponatremia and fluid loss from vomiting.
It helps restore sodium levels without the risk of overcorrection seen with 0.9% NaCl.
Choice B rationale:
“This fluid will help to lower my sodium levels and replace the fluids I lost from sweating.”.
Half Normal Saline is not used to lower sodium levels; its purpose is to restore sodium levels and provide fluids for cases like vomiting or other fluid losses.
Sweating typically leads to fluid loss, not sodium loss, and Half Normal Saline is not a treatment for high sodium levels.
Choice C rationale:
“This fluid will help to restore my potassium levels and replace the fluids I lost from vomiting.”.
Half Normal Saline does not address potassium levels, and the primary reason for using it is to address sodium imbalances and fluid loss, not potassium-related issues.
Choice D rationale:
“This fluid will help to lower my potassium levels and replace the fluids I lost from sweating.”.
Half Normal Saline is not used to lower potassium levels and is not specifically indicated for treating high potassium.
Additionally, it is not typically used to address fluid loss from sweating.
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