A nurse is preparing to calculate fluid replacement for a dehydrated child.
Which of the following steps should the nurse take? (Select all that apply).
Assess the degree of dehydration based on clinical signs and symptoms.
Calculate the fluid deficit based on the degree of dehydration.
Administer electrolyte solutions or supplements as necessary.
Monitor the child’s response to treatment and adjust the plan accordingly.
Communicate with physicians, nutritionists, and other healthcare professionals to ensure comprehensive care.
Correct Answer : A,B,D,E
Choice A rationale:
Assessing the degree of dehydration based on clinical signs and symptoms is a fundamental step in managing a dehydrated child.
This assessment guides the choice of appropriate treatment and fluid replacement.
Choice B rationale:
Calculating the fluid deficit based on the degree of dehydration is crucial in determining the amount of fluid that needs to be replaced accurately.
This calculation helps prevent under or overhydration.
Choice D rationale:
Monitoring the child's response to treatment and adjusting the plan accordingly is essential.
Dehydration management is an ongoing process, and adjustments may be necessary based on how the child is progressing.
Choice E rationale:
Communication with physicians, nutritionists, and other healthcare professionals is vital for comprehensive care.
Dehydration management often involves a multidisciplinary approach to address the child's overall health and nutritional needs.
Selecting all of these options (A, B, D, and E) ensures a comprehensive approach to managing dehydration in a child.
It involves assessment, calculation, monitoring, and collaboration with healthcare professionals for the best outcome.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Maintaining a warm room temperature is not the key to preventing dehydration.
Dehydration occurs when the body loses more fluids than it takes in, and temperature control in the room doesn't directly address this issue.
Choice B rationale:
The significance of oral rehydration solution (ORS) is a crucial factor in preventing and treating dehydration.
ORS contains a balanced mixture of salts and sugars that help the body reabsorb water and electrolytes lost due to dehydration.
It is the most effective way to rehydrate a dehydrated child.
Educating the client about the importance of ORS is essential because it provides a clear solution to the problem of dehydration.
Choice C rationale:
The need for a complete blood count (CBC) testing is unrelated to the prevention of dehydration.
CBC is a diagnostic test used to assess various blood parameters, including red and white blood cell counts.
It is not a preventive measure against dehydration.
Choice D rationale:
Suggesting the child's need for frequent, heavy meals is not an appropriate way to prevent dehydration.
In fact, heavy meals can sometimes worsen dehydration as they may be difficult to digest, leading to an increased risk of vomiting and diarrhea, which exacerbate fluid loss.
Correct Answer is C
Explanation
Choice A rationale:
Vital signs are essential in assessing dehydration.
An elevated heart rate may indicate compensatory mechanisms due to decreased intravascular volume.
Low blood pressure may suggest severe dehydration, and abnormal temperature may indicate an underlying infection.
These parameters provide crucial information about the child's circulatory status, helping to assess the severity of dehydration.
Choice B rationale:
Physical examination findings, such as skin turgor and mucous membrane moisture, are valuable indicators of dehydration.
Poor skin turgor, where the skin doesn't return to its normal position promptly when pinched, indicates decreased tissue turgor due to fluid loss.
Dry mucous membranes, including the mouth, suggest dehydration and help evaluate the extent of fluid deficit.
These signs offer direct visual clues about the child's hydration status.
Choice C rationale:
Laboratory tests play a significant role in diagnosing dehydration.
A complete blood count (CBC) helps identify elevated hematocrit levels, indicating hemoconcentration due to fluid loss.
Electrolyte levels, specifically sodium and potassium, provide insights into the child's electrolyte balance, which can be disrupted in dehydration.
Urine specific gravity measures the kidney's ability to concentrate urine; a high specific gravity suggests concentrated urine due to reduced fluid intake.
These tests aid in confirming the diagnosis and assessing the severity of dehydration.
Choice D rationale:
Assessing the child's history is fundamental in understanding the underlying cause of dehydration.
Recent fluid intake and urine output patterns help determine the balance between intake and output.
Symptoms such as diarrhea, vomiting, and fever indicate potential causes of fluid loss.
Additionally, evaluating the child's overall health and any recent illnesses provides context for the dehydration, guiding appropriate treatment.
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