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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.”..

Answer and Explanation

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.

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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.

A. Approximately 58 mL/hour. B. Approximately 140 mL/hour. C. Approximately 100 mL/hour. D. Approximately 82 mL/hour.

Correct Answer is C

Explanation

Approximately 100 mL/hour.

To calculate the total hourly fluid replacement rate, we can use the Holliday-Segar method, which is commonly used in pediatrics.

According to this method, a child's daily maintenance fluid requirement is calculated as follows: For the first 10 kg of body weight: 100 mL/kg/day.

For the next 10 kg of body weight: 50 mL/kg/day.

For each additional kg of body weight: 20 mL/kg/day.

In this case, the child weighs 14 kg.

So, we calculate as follows: For the first 10 kg: 10 kg x 100 mL/kg/day = 1000 mL/day.

For the next 4 kg (14 kg - 10 kg): 4 kg x 50 mL/kg/day = 200 mL/day.

Now, add these two together: 1000 mL/day + 200 mL/day = 1200 mL/day.

To find the hourly rate, we divide the daily requirement by 24 (hours in a day): 1200 mL/day ÷ 24 hours/day = 50 mL/hour.

So, the child's total hourly fluid replacement rate should be approximately 50 mL/hour.

However, this is an approximate rate.

To be more conservative in the case of severe dehydration, it's common to round this up to approximately 100 mL/hour to ensure that the child receives adequate fluids to rehydrate.

Choice A rationale:

Approximately 58 mL/hour is not The correct answer.

This calculation does not match the standard Holliday-Segar method used in pediatrics for fluid replacement.

Choice B rationale:

Approximately 140 mL/hour is not The correct answer.

This calculation significantly exceeds the recommended hourly fluid replacement rate for a child of this weight, which could potentially lead to overhydration.

Choice D rationale:

Approximately 82 mL/hour is not The correct answer.

This calculation does not align with the standard method for calculating fluid replacement in pediatric patients.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is caring for a child with severe dehydration who weighs 14 kg.What would be the total hourly fluid replacement rate for this child?

Correct Answer is C

Explanation

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