A nurse is assessing a client who has dehydration due to prolonged diarrhea. Which of the following findings should the nurse expect?

Bradycardia

Edema

Hypotension

Crackles

Answer and Explanation

The Correct Answer is C

A. Bradycardia is not expected with dehydration. Instead, tachycardia occurs as a compensatory response to low blood volume.
B. Edema is not a symptom of dehydration. Instead, dehydration leads to decreased tissue perfusion and dry mucous membranes.
C. Hypotension occurs due to decreased blood volume from fluid loss, leading to low blood pressure and potential dizziness or weakness.
D. Crackles are not expected in dehydration. Instead, lung sounds are typically clear unless another condition is present.

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Correct Answer is A

Explanation

A. Keeping the umbilical cord area clean and dry helps prevent infection. Washing the base of the cord with water is recommended, while avoiding full immersion in water until the cord falls off.
B. The diaper should be folded down below the cord to prevent moisture buildup and irritation. Covering it can trap moisture and increase the risk of infection.
C. Minor bleeding is not expected when the stump falls off. Persistent or excessive bleeding should be reported to the provider.
D. Petroleum jelly is not recommended for umbilical cord care. The cord should be kept dry to facilitate natural detachment.

A. Antibiotic therapy B. Protective environment C. Blood transfusion D. Iron supplementation

Correct Answer is D

Explanation

A. Antibiotic therapy. This is incorrect because there is no indication of an infection. The WBC count is within the normal range, and there are no symptoms suggestive of a bacterial infection.
B. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, such as those undergoing chemotherapy or with severe neutropenia, which is not the case here.
C. Blood transfusion. This is incorrect because although the hemoglobin level is low (8.1 g/dL), it is not critically low enough to require a transfusion. Instead, iron supplementation is the preferred treatment.
D. Iron supplementation. This is correct because the child’s hemoglobin and hematocrit levels indicate mild anemia, likely due to excessive cow’s milk intake, which can lead to iron deficiency anemia in toddlers. Iron supplementation will help correct the deficiency.

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A nurse is assessing a client who has dehydration due to prolonged diarrhea. Which of the following findings should the nurse expect?

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