A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect?
13% weight loss.
Bulging anterior fontanel.
Bradypnea.
Capillary refill 3 seconds.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale
A 13% weight loss indicates severe dehydration. Dehydration is classified based on the percentage of body weight lost, with severe dehydration being more than 10%6.
Choice B rationale
A bulging anterior fontanel is a sign of increased intracranial pressure, not dehydration. In dehydration, the fontanel is typically sunken due to fluid loss.
Choice C rationale
Bradypnea, or slow breathing, is not a common sign of dehydration. Dehydration often leads to tachypnea, or rapid breathing, as the body tries to compensate for fluid loss.
Choice D rationale
A capillary refill time of 3 seconds is within normal limits. In severe dehydration, capillary refill time is usually prolonged, indicating poor perfusion.
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Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
The influenza vaccine is recommended annually for all individuals, including adolescents, to protect against the flu. However, it is not specifically required for pre-college physical assessments.
Choice B rationale
The pneumococcal polysaccharide vaccine is typically administered to older adults and individuals with certain medical conditions. It is not a standard requirement for adolescents.
Choice C rationale
The Bacille Calmette-Guérin (BCG) vaccine is used in countries with a high prevalence of tuberculosis. It is not commonly administered in the United States or required for pre-college physical assessments.
Choice D rationale
The meningococcal polysaccharide vaccine is recommended for adolescents, especially those entering college, to protect against meningococcal disease, which can spread in close living quarters.
Correct Answer is ["3.6"]
Explanation
Step 1: Convert the child’s weight from pounds to kilograms. 66 lb ÷ 2.2 = 30 kg
Step 2: Calculate the total daily dose of digoxin. 12 mcg/kg/day × 30 kg = 360 mcg/day
Step 3: Divide the total daily dose by 2 to get the dose for every 12 hours. 360 mcg/day ÷ 2 = 180 mcg/dose
Step 4: Convert mcg to mg. 180 mcg = 0.18 mg Step 5: Calculate the volume to administer per dose using the concentration of the elixir. 0.18 mg ÷ 0.05 mg/mL = 3.6 mL
Final calculated answer: 3.6 mL per dose.
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