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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Educate the parents about potential complications: While education is important, it is not the immediate priority.
B. Maintain a saline lock: Maintaining IV access is essential but does not directly address fluid balance, the primary concern.
C. Place the child on a no-salt-added diet: While reducing salt helps control edema, daily weight monitoring is more immediate for assessing fluid retention.
D. Check the child's weight daily: Monitoring weight is the most sensitive indicator of fluid retention and is crucial for evaluating the child's response to treatment.

A. Golf ball-size mass over the left quadrant B. Increased sodium level C. Absent bowel sounds D. Projectile vomiting after feedings

Correct Answer is D

Explanation

A. Golf ball-size mass over the left quadrant: The mass associated with pyloric stenosis is in the right upper quadrant, not the left.
B. Increased sodium level: Electrolyte imbalances in pyloric stenosis typically involve hypochloremia and metabolic alkalosis, not increased sodium.
C. Absent bowel sounds: Bowel sounds are usually present unless there is severe dehydration or ileus.
D. Projectile vomiting after feedings: Projectile vomiting is a classic symptom of pyloric stenosis due to obstruction.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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