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.
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Related Questions
Correct Answer is D
Explanation
A. Assess fluid balance: Although assessment is important, rehydration takes priority to address the acute loss of fluids and electrolytes.
B. Maintain fluid therapy: Fluid therapy maintenance is secondary to initiating rehydration.
C. Introduce a regular diet: Diet modification is less critical than rehydration in the acute phase.
D. Rehydrate: Rehydration addresses the immediate risk of dehydration and electrolyte imbalance caused by severe diarrhea.
Correct Answer is ["A","B","D"]
Explanation
A. Wheezing: Reflux of stomach contents can cause aspiration, leading to wheezing or respiratory symptoms.
B. Weight Loss: Chronic vomiting and poor feeding due to GER can result in inadequate weight gain or weight loss.
C. Pallor: Pallor is not commonly associated with GER but may indicate anemia or another condition.
D. Vomiting: Vomiting, especially after feeding, is a hallmark sign of GER.
E. Rigid Abdomen: A rigid abdomen is more indicative of severe abdominal pathology like peritonitis, not GER.
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