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 B
Explanation
Choice A reason: Watching a video game in the playroom is not a good activity for a child who requires airborne precautions, as it may expose the child and other children to the risk of infection. Airborne precautions are used for patients who have diseases that are transmitted by small droplets that can remain suspended in the air and travel over long distances, such as tuberculosis, chickenpox, or measles. The child should stay in a private room with negative air pressure, high-efficiency particulate air (HEPA) filtration, and respiratory protection for health care workers and visitors.
Choice B reason: Putting a large-piece puzzle together is a good activity for a child who requires airborne precautions, as it can be done in the child's room and does not involve close contact with others. It is also developmentally appropriate for a 4-year-old child, as it helps to develop fine motor skills, cognitive skills, and problem-solving skills. The nurse should provide the child with a variety of puzzles that are colorful, fun, and challenging, but not frustrating.
Choice C reason: Constructing a model airplane is not a good activity for a child who requires airborne precautions, as it may involve small pieces that can be easily lost, swallowed, or inhaled. It may also be too difficult or complex for a 4-year-old child, who may not have the attention span, dexterity, or patience to complete the task. The nurse should choose activities that are safe, simple, and suitable for the child's age and abilities.
Choice D reason: Pulling a wagon with toys in the hallway is not a good activity for a child who requires airborne precautions, as it may expose the child and other people to the risk of infection. The child should not leave the room unless it is necessary for diagnostic or therapeutic procedures. If the child has to leave the room, the nurse should ensure that the child wears a mask and follows the infection control guidelines. The nurse should also minimize the movement and transport of the child.
Correct Answer is B
Explanation
Choice A reason: Fifth disease is a viral infection that causes a rash on the face and body. It is also known as erythema infectiosum or slapped cheek syndrome. It is not the same as pertussis.
Choice B reason: Whooping cough is a bacterial infection that causes severe coughing spells that end with a whooping sound. It is also known as pertussis or the 100-day cough. It is the correct common name for the disease.
Choice C reason: Chickenpox is a viral infection that causes an itchy rash with blisters. It is also known as varicella. It is not the same as pertussis.
Choice D reason: Mumps is a viral infection that causes swelling of the salivary glands. It is also known as parotitis. It is not the same as pertussis.
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