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.
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Related Questions
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.
Correct Answer is A
No explanation
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