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 B
Explanation
A. Collect a stool sample from the toddler: This is important but not the priority. Dehydration status must be assessed first.
B. Determine if the toddler is voiding: Assessing for urination helps evaluate hydration status and guides fluid replacement.
C. Initiate isotonic fluids with 20 mEq/L potassium chloride: Potassium should not be added until kidney function and voiding are confirmed.
D. Request evaluation of the toddler’s serum electrolytes: This is important but comes after assessing hydration and kidney function.
Correct Answer is B
Explanation
A. Polyuria: Nephrotic syndrome typically causes oliguria, not polyuria.
B. Periorbital edema: Fluid retention due to hypoalbuminemia commonly manifests as periorbital edema, especially in the morning.
C. Orange-tinged urine. This is not a characteristic of nephrotic syndrome. Urine may appear foamy due to proteinuria.
D. Hypertension: While hypertension can occur in some renal disorders, it is not a primary feature of nephrotic syndrome, which is characterized by edema, hypoalbuminemia, and proteinuria.
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