A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?
Respiratory rate of 24 breaths/min
Heart rate of 130/min
Urine specific gravity of 1.015
Capillary refill of greater than 3 seconds
The Correct Answer is C
Choice A reason: A respiratory rate of 24 breaths/min is within the normal range for a 3-year-old child. It does not indicate the degree of hydration or dehydration of the child.
Choice B reason: A heart rate of 130/min is above the normal range for a 3-year-old child, which is 80 to 120/min. It may indicate dehydration, fever, pain, or anxiety. It does not indicate the effectiveness of oral rehydration therapy.
Choice C reason: A urine specific gravity of 1.015 is within the normal range for a child, which is 1.005 to 1.030. It indicates that the child's urine is adequately concentrated and that the child is well hydrated. It is a reliable indicator of the effectiveness of oral rehydration therapy.
Choice D reason: A capillary refill of greater than 3 seconds is abnormal and indicates poor peripheral perfusion. It may be a sign of dehydration, shock, or hypothermia. It does not indicate the effectiveness of oral rehydration therapy.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Assess the rest of the child's body for a rash.
The child's red marks across the cheeks are characteristic of fifth disease (also known as erythema infectiosum). Fifth disease is caused by parvovirus B19 and typically presents with a bright red rash on the cheeks, often referred to as "slapped cheek" appearance. The rash may eventually spread to other areas of the body, including the arms, trunk, thighs, and buttocks. It is usually mild and self-limiting.
Choice B reason: This option is not appropriate for a rash caused by fifth disease. There is no indication of child abuse or neglect.
Choice C reason: The rash is due to a viral infection and not related to trauma or injury. Questioning the parents is unnecessary.
Choice D reason: While assessing the child's temperature is important in general nursing care, it is not specifically related to the red marks on the cheeks in this case.
Correct Answer is ["B"]
Explanation
Choice A reason: Polyuria, or excessive urination, is not a sign of low blood glucose level, but of high blood glucose level. It is caused by osmotic diuresis, which occurs when the kidneys try to flush out the excess glucose from the blood.
Choice B reason: Tachycardia, or fast heart rate, is a sign of low blood glucose level. It is caused by the activation of the sympathetic nervous system, which releases adrenaline and other hormones to increase the blood glucose level and stimulate the heart.
Choice C reason: Dry, flushed skin is not a sign of low blood glucose level, but of high blood glucose level. It is caused by dehydration, which occurs when the body loses fluid due to polyuria and increased thirst.
Choice D reason: Deep, rapid respirations are not a sign of low blood glucose level, but of diabetic ketoacidosis, a complication of high blood glucose level. It is caused by the accumulation of ketones, which are acidic substances produced when the body breaks down fat for energy due to lack of insulin.
Choice E reason: Hunger is a sign of low blood glucose level. It is caused by the lack of glucose in the cells, which are the main source of energy for the body. The brain signals the body to eat more to raise the blood glucose level.
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