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 B
The correct answer is: b.
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 of 1.015 is within the normal range (1.005–1.030) for a hydrated child. Dehydration increases urine concentration (>1.020), but a normalized value like 1.015 shows that ORT has restored fluid balance. UpToDate and NIH studies (e.g., Binder et al., 2014) highlight urine specific gravity as a precise measure of hydration status, making it the strongest indicator of ORT effectiveness.
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 of less than 3 seconds suggests adequate perfusion, as normal is under 2 seconds. Dehydration may prolong this time, but “less than 3 seconds” could include slightly delayed values (e.g., 2.5 seconds). UpToDate and NIH studies (e.g., Doan et al., 2010) note it as useful but less specific than urine specific gravity for confirming ORT effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Nephritic syndrome is a kidney disorder that causes inflammation and damage to the glomeruli, the filtering units of the kidneys. It can cause hematuria (blood in the urine), proteinuria (protein in the urine), hypertension (high blood pressure), and edema (swelling). However, it does not cause a palpable abdominal mass, which is a characteristic sign of Wilms tumor.
Choice B reason: Wilms tumor is a malignant tumor of the kidney that occurs mainly in children under 5 years of age. It can cause a large, firm, and painless abdominal mass, hematuria, abdominal pain, fever, and hypertension. It is the most common renal tumor in children and requires prompt diagnosis and treatment.
Choice C reason: Pyloric stenosis is a condition that causes narrowing of the pylorus, the outlet of the stomach. It can cause projectile vomiting, dehydration, weight loss, and a palpable olive-shaped mass in the upper abdomen. However, it does not cause hematuria or a large abdominal mass.
Choice D reason: Intussusception is a condition that occurs when a part of the intestine slides into another part, causing a blockage. It can cause abdominal pain, vomiting, bloody stools, and a sausage-shaped mass in the abdomen. However, it does not cause hematuria or a large abdominal mass.
Correct Answer is A
Explanation
Choice A reason: A child who has rheumatic fever is a suitable roommate for a child who has leukemia, as rheumatic fever is not a contagious condition, and it does not pose any risk of infection or cross-reaction to the child who has leukemia. Rheumatic fever is an inflammatory disease that can affect the heart, joints, skin, and brain, and it is caused by a delayed immune response to a streptococcal infection.
Choice B reason: A child recovering from a ruptured appendix is not a suitable roommate for a child who has leukemia, as a ruptured appendix can cause peritonitis, which is a serious infection of the abdominal cavity, and it can be a source of bacteria or fungi that can spread to the child who has leukemia. A child who has leukemia has a compromised immune system and is susceptible to infections.
Choice C reason: A child who has nephrotic syndrome is not a suitable roommate for a child who has leukemia, as nephrotic syndrome can cause edema, proteinuria, hypoalbuminemia, and hyperlipidemia, and it can be associated with infections, allergies, or autoimmune disorders that can affect the child who has leukemia. A child who has leukemia has a reduced number of blood cells and is prone to bleeding, anemia, and infections.
Choice D reason: A child who has cystic fibrosis is not a suitable roommate for a child who has leukemia, as cystic fibrosis is a genetic disorder that affects the lungs, pancreas, liver, and intestines, and it can cause chronic respiratory infections, malabsorption, and diabetes, which can compromise the health of the child who has leukemia. A child who has leukemia has a weakened immune system and is vulnerable to infections.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.