A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first?
Hypotension
Tachypnea
Нурегругехіа
Skin breakdown
The Correct Answer is A
A. Hypotension is the most critical finding in dehydration, as it indicates severe fluid loss and can lead to shock. Immediate intervention is required to address the circulatory compromise.
B. Tachypnea is a compensatory response to dehydration and may not require as immediate attention as hypotension.
C. Hyperpyrexia (high fever) can occur in gastroenteritis but is less urgent compared to hypotension.
D. Skin breakdown is a concern in dehydrated patients, but hypotension poses a more immediate threat to life.
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Related Questions
Correct Answer is B
Explanation
A. Elevating the head of the bed may be useful after airway management but is not the priority in anaphylaxis.
B. Administering IM epinephrine is the priority action in anaphylaxis, as it works rapidly to reverse the symptoms by constricting blood vessels, relaxing smooth muscles, and improving breathing.
C. Determining the allergen is important for future prevention, but the immediate priority is treating the reaction.
D. While establishing IV access is important for fluid resuscitation, it is not the priority over administering epinephrine in anaphylaxis.
Correct Answer is D
Explanation
A. Weak femoral pulses may be seen in other congenital heart defects but are not typically associated with VSD.
B. High blood pressure is not a typical finding in VSD, as the defect usually leads to increased blood flow to the lungs rather than systemic hypertension.
C. Dysrhythmias are not commonly associated with VSD unless there are other complicating factors.
D. A loud, harsh murmur is a classic finding in infants with a ventricular septal defect (VSD), due to the abnormal flow of blood through the hole in the septum.
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