A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?
Heart rate 130/min
Urine specific gravity 1.015
Respiratory rate 24/min
Capillary refill less than 3 seconds
None
None
The Correct Answer is D
The correct answer is: d. Capillary refill less than 3 seconds
Choice A: Heart rate 130/min
A heart rate of 130 beats per minute (bpm) is considered high for a 3-year-old child. Normal heart rates for children aged 1-3 years typically range from 80 to 120 bpm. While dehydration can cause tachycardia (increased heart rate), a heart rate of 130 bpm does not necessarily indicate effective rehydration.
Choice B: Urine specific gravity 1.015
Urine specific gravity measures the concentration of solutes in the urine. Normal ranges for urine specific gravity in children are typically between 1.005 and 1.030. A value of 1.015 falls within the normal range, suggesting adequate hydration. However, it is not the most direct indicator of effective rehydration therapy.
Choice C: Respiratory rate 24/min
The normal respiratory rate for a 3-year-old child is between 20 and 30 breaths per minute. A respiratory rate of 24 breaths per minute is within this normal range. While a normal respiratory rate can indicate improved hydration status, it is not the most specific indicator of effective rehydration therapy.
Choice D: Capillary refill less than 3 seconds
Capillary refill time is a reliable indicator of effective rehydration. Normal capillary refill time is less than 2 seconds. A capillary refill time of less than 3 seconds suggests that the child’s circulatory status has improved, indicating effective rehydration therapy. This is a direct and observable sign that the child’s perfusion and hydration status have normalized.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Bleeding precaution is indicated for a child who has leukemia and a critically low platelet count, as it reduces the risk of hemorrhage and injury. The nurse should monitor the child for signs of bleeding, such as petechiae, ecchymosis, epistaxis, hematuria, and melena. The nurse should also avoid invasive procedures, use soft-bristled toothbrushes, apply pressure to venipuncture sites, and administer platelet transfusions as prescribed.
Choice B reason: Droplet precaution is not indicated for a child who has leukemia and a critically low platelet count, unless the child has a respiratory infection that is transmitted by droplets. Droplet precaution involves wearing a mask when within 3 feet of the child, and placing the child in a private room or with a roommate who has the same infection.
Choice C reason: Neutropenic precaution is indicated for a child who has leukemia and a critically low neutrophil count, as it reduces the risk of infection and sepsis. Neutropenic precaution involves placing the child in a private room with positive pressure airflow, wearing gloves, gown, and mask when entering the room, and restricting visitors who are ill or immunocompromised.
Choice D reason: Contact precaution is not indicated for a child who has leukemia and a critically low platelet count, unless the child has a skin or wound infection that is transmitted by direct or indirect contact. Contact precaution involves wearing gloves and gown when entering the room, and placing the child in a private room or with a roommate who has the same infection.
Correct Answer is ["B","C"]
Explanation
Choice A reason: Retinopathy is not a potential issue for a child who has leukemia, as it is a condition that affects the blood vessels of the retina, which can be caused by diabetes, hypertension, or sickle cell disease. Leukemia does not affect the retina, but it can cause blurred vision, eye pain, or headaches due to increased intracranial pressure or cranial nerve involvement.
Choice B reason: Hemorrhage is a potential issue for a child who has leukemia, as it is a condition that causes excessive bleeding, which can be caused by thrombocytopenia, coagulopathy, or bone marrow suppression. Leukemia can cause a low platelet count, which impairs the blood clotting process and increases the risk of bleeding from minor injuries, mucous membranes, or internal organs.
Choice C reason: Neuropathy is a potential issue for a child who has leukemia, as it is a condition that affects the nerves, which can be caused by chemotherapy, radiation, infection, or compression. Leukemia can cause nerve damage, which can result in numbness, tingling, pain, or weakness in the extremities, face, or trunk.
Choice D reason: Rheumatoid arthritis is not a potential issue for a child who has leukemia, as it is a condition that affects the joints, which can be caused by an autoimmune disorder, inflammation, or infection. Leukemia does not affect the joints, but it can cause bone pain, swelling, or fractures due to bone marrow infiltration or osteoporosis.
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