A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?
Respiratory rate 28/min
Capillary refill 1 second
Weight loss 7%
Bradycardia
The Correct Answer is A
A. A respiratory rate of 28 breaths per minute indicates increased respiratory effort, which can be a sign of moderate dehydration. The infant may be trying to compensate for fluid
loss.
B. Capillary refill of 1 second is within the normal range (less than 2 seconds). It is not indicative of moderate dehydration.
C. Weight loss of 7% is a significant amount of weight loss and is indicative of severe dehydration, not moderate dehydration. Moderate dehydration is usually defined as 5- 10% weight loss.
D. Bradycardia (slow heart rate) is not typically associated with dehydration. In fact, tachycardia (fast heart rate) is a more common sign of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.
C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
Correct Answer is D
Explanation
A. Abrasions on the knees may be common in active children and may not necessarily indicate physical abuse.
B. Front deciduous teeth missing is a normal occurrence as children lose their baby teeth and grow permanent teeth. It is not indicative of physical abuse.
C. Weight in the 45th percentile indicates that the child's weight falls within the average range for their age. This finding is not indicative of physical abuse.
D. Bruising around the wrists can be a concerning sign, especially if it suggests that the child has been restrained or grabbed forcefully. This finding raises suspicion of physical abuse and should be further assessed and reported if necessary.
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