A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?
Respiratory rate 24/min>
Urine specific gravity 1.015
Heart rate 130/min
Capillary refill greater than 3 seconds
The Correct Answer is B
A. Respiratory rate 24/min: While a normal respiratory rate is positive, it is not a primary marker of hydration status.
B. Urine specific gravity 1.015: A normal urine specific gravity indicates adequate hydration.
C. Heart rate 130/min: Tachycardia indicates ongoing dehydration or stress.
D. Capillary refill greater than 3 seconds: Prolonged capillary refill suggests inadequate perfusion and continued dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Ribbonlike, foul-smelling stools. This is a classic symptom of Hirschsprung disease due to chronic constipation and obstruction from the absence of ganglion cells in the rectum.
B. Projectile vomiting. Projectile vomiting is associated with pyloric stenosis, not Hirschsprung disease.
C. Chronic hunger. This is also indicative of pyloric stenosis rather than Hirschsprung disease.
D. Ridged abdomen. While abdominal distension may occur, a ridged abdomen is not specific to Hirschsprung disease.
Correct Answer is A
Explanation
A. Air or Barium enema: This is both diagnostic and therapeutic. The enema can reduce the intussusception by relieving the telescoping of the bowel.
B. IV fluids until spasm subsides: While IV fluids are used to manage dehydration, they do not resolve intussusception.
C. Immediate surgery: Surgery is reserved for cases where enemas are unsuccessful or complications like perforation occur.
D. Gastric gavage: This is not related to treating intussusception and does not address the underlying issue.
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