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?
Skin integrity
Respiratory rate
Body weight
Blood pressure
The Correct Answer is C
In an infant with a history of vomiting and fever, body weight is the most reliable indicator of fluid loss. Monitoring the infant's weight over time can help assess the degree of dehydration and guide the appropriate fluid replacement therapy. A significant decrease in body weight suggests significant fluid loss.
Option A: Skin integrity is important to assess for signs of dehydration, but it is not as reliable as body weight in determining the extent of fluid loss.
Option B: Respiratory rate can be affected by various factors and is not a direct indicator of fluid loss.
Option D: Blood pressure is not the most reliable indicator of fluid loss in an infant with dehydration. In severe cases of dehydration, blood pressure can drop, but it is not as sensitive as body weight in assessing the extent of fluid loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Severe anemia is a condition characterized by a significant decrease in the number of red blood cells or hemoglobin in the blood, leading to reduced oxygen-carrying capacity. This can result in fatigue, weakness, and shortness of breath in the affected individual.
A red blood cell transfusion is given to a child with severe anemia to increase the number of red blood cells and, consequently, the hemoglobin level in the blood. This helps improve oxygen delivery to tissues and organs, which can lead to increased energy levels and reduced fatigue.
Option A is incorrect because red blood cell transfusion is not given to help the body stop bleeding by forming a clot. Platelets are responsible for clot formation, not red blood cells.
Option B is incorrect because a red blood cell transfusion is not used to fight infections. White blood cells and the immune system are responsible for fighting infections.
Option D is incorrect because a red blood cell transfusion is not given to allow her parents to come to visit her. Transfusions are medical treatments to address specific medical conditions and are not related to visitation rights.
Correct Answer is C
Explanation
A. Broth: While broth can be a source of fluids, it does not contain the appropriate balance of electrolytes needed to rehydrate the body effectively. Gastroenteritis can cause significant fluid and electrolyte loss, so an oral rehydration solution (ORS) with the right proportions of salts and sugars is essential to replace these losses adequately.
B. Diluted apple juice: Diluted apple juice may not provide the proper electrolyte balance needed for rehydration in cases of gastroenteritis. In fact, apple juice is not recommended during episodes of acute gastroenteritis, as it can worsen diarrhea due to its high sugar content. This can lead to further dehydration and discomfort.
C. Oral rehydration solution (ORS): This is the correct answer. Oral rehydration solution is specifically designed to replace lost fluids and electrolytes in cases of gastroenteritis. It contains the right balance of salts and sugars to facilitate effective absorption in the intestines and help rehydrate the body. ORS is the recommended fluid for managing dehydration caused by gastroenteritis in children.
D. Water: While water is essential for hydration, it is not enough to effectively treat dehydration caused by gastroenteritis. Plain water does not contain the necessary electrolytes like sodium, potassium, and chloride, which are lost during episodes of diarrhea and vomiting. Giving water alone may not adequately rehydrate the child and could potentially worsen the dehydration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.