A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature.
Which of the following should the nurse recognize as the most reliable indicator of fluid loss?
Blood pressure.
Respiratory rate.
Body weight.
Skin integrity.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale
Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.
Choice B rationale
Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.
Choice C rationale
Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.
Choice D rationale
Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Measuring head circumference every shift is unnecessary for a 6-year-old child with bacterial meningitis. This intervention is more relevant for infants where head circumference changes can indicate increased intracranial pressure.
Choice B rationale
Implementing seizure precautions is necessary as bacterial meningitis can cause seizures due to increased intracranial pressure and inflammation.
Choice C rationale
Admitting the client to a private room is necessary to prevent the spread of infection, as bacterial meningitis can be highly contagious.
Choice D rationale
Placing the client in a semi-Fowler’s position helps reduce intracranial pressure and promotes comfort.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Droplet precautions are used for infections spread through large respiratory droplets, such as influenza, but are not sufficient for measles.
Choice B rationale
Airborne precautions are necessary for measles, as it is spread through small droplets that can remain suspended in the air and travel over long distances.
Choice C rationale
Contact precautions are used for infections spread through direct contact with the patient or their environment, such as MRSA, but are not sufficient for measles.
Choice D rationale
A protective environment is used for patients with compromised immune systems to protect them from infections, not for preventing the spread of infections like measles.
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