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 D
Explanation
The nurse's priority assessment finding in an adolescent who experienced blunt trauma to the abdomen is low blood pressure (hypotension). Hypotension could indicate significant internal bleeding or hemorrhage, which is a life-threatening condition and requires immediate attention. The decreased blood pressure may be a sign of shock, and prompt intervention is needed to stabilize the client's condition and prevent further deterioration.
While all the other findings (respiratory rate, abdominal pain, and heart rate) are important and should be assessed and monitored, blood pressure is the most critical in this situation due to its potential association with severe internal injuries and the risk of hypovolemic shock.
Correct Answer is D
Explanation
When caring for a child with acute appendicitis, the nurse should anticipate an elevated white blood cell count (WBC) in the laboratory values. A high WBC count is a common finding in acute appendicitis, as it indicates an inflammatory response and infection in the body. The body's immune system responds to the inflammation caused by the infected appendix, leading to an increase in WBCs to fight off the infection.
The other options are not necessarily specific to acute appendicitis:
A. RBC 4.2 million/mm³: The red blood cell count (RBC) measures the number of red blood cells in the bloodstream. This value may be within the normal range, but it is not the primary marker for diagnosing or monitoring acute appendicitis.
B. Lymphocytes 3,000/mm3: Lymphocytes are a type of white blood cell involved in the body's immune response. While changes in lymphocyte levels can occur during inflammation, it is not the primary marker for diagnosing or monitoring acute appendicitis.
C. Neutrophils 3.000/mm³: Neutrophils are a type of white blood cell that increases in response to infection and inflammation. However, the absolute neutrophil count is not as relevant as the overall WBC count in determining the presence and severity of acute appendicitis.
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