A nurse is caring for a child who has dehydration. Which of the following findings should the nurse expect?
Hct 45%.
Urine specific gravity 1.035.
Capillary refill less than 2 seconds.
Urine output 35 ml/hr.
The Correct Answer is B
Choice A rationale:
Hct 45% (Choice A) refers to the hematocrit level, which measures the proportion of blood volume occupied by red blood cells. While dehydration can lead to elevated hematocrit due to hemoconcentration, a hematocrit value of 45% is within the normal range for both males and females. Dehydration might cause a mild increase, but more significant elevations would be expected in cases of severe dehydration.
Choice B rationale:
Urine specific gravity 1.035 (Choice B) is an indicator of concentrated urine, which is a characteristic finding in dehydration. Dehydration reduces the body's water content, leading to more concentrated urine with higher specific gravity values. A normal range for urine-specific gravity is typically between 1.005 and 1.030.
Choice C rationale:
Capillary refill of less than 2 seconds (Choice C) is not a finding consistent with dehydration. Capillary refill time measures the time it takes for color to return to the nailbed after pressure is applied. Prolonged capillary refill time might indicate poor peripheral perfusion, which can be a sign of dehydration, but a refill time of less than 2 seconds is considered within the normal range.
Choice D rationale:
A urine output of 35 ml/hr (Choice D) is not indicative of dehydration. In fact, a urine output of 35 ml/hr is relatively normal and suggests adequate fluid intake and hydration. Dehydration would typically result in reduced urine output as the body conserves water.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Tinnitus is the perception of noise or ringing in the ears. It can be caused by various factors, including exposure to loud noises, ear infections, and certain medications. However, tinnitus is not a commonly reported adverse effect of albuterol, which is a bronchodilator used to treat conditions like asthma and other respiratory disorders.
Choice B rationale:
Constipation is not a commonly reported adverse effect of albuterol. Albuterol primarily acts on the smooth muscles of the airways to relax and dilate them, improving airflow. Constipation is more likely related to issues with the gastrointestinal system or certain medications, but it is not a direct consequence of albuterol use.
Choice C rationale:
Hypoglycemia, or low blood sugar, is not a known adverse effect of albuterol. Albuterol primarily affects the respiratory system and does not typically impact blood glucose levels. Hypoglycemia is more commonly associated with diabetes medications like insulin or certain oral hypoglycemic agents.
Choice D rationale:
Headache is a potential adverse effect of albuterol. While not everyone will experience a headache when taking albuterol, it can occur as a side effect in some individuals. Albuterol can stimulate the sympathetic nervous system, leading to effects such as increased heart rate and potential vasodilation, which could contribute to the development of a headache in some cases. It's important for the parents of a child taking albuterol to be aware of potential side effects and report them to the healthcare provider if they occur.
Correct Answer is B
Explanation
Choice A rationale:
Avoiding discussions about the child's diagnosis with the sibling might create confusion and anxiety for the sibling. Open communication is essential for helping siblings understand their brother or sister's condition and cope with the changes in the family dynamic.
Choice B rationale:
Encouraging phone calls between the siblings is a positive step in promoting sibling adaptation when one of them has a chronic illness like cystic fibrosis. Maintaining connections through communication helps siblings feel involved, valued, and informed about each other's lives and challenges.
Choice C rationale:
Designating one parent to stay at home with the sibling might lead to feelings of isolation and neglect for the child with cystic fibrosis. Siblings also need support and attention during this time, and isolating one parent could hinder healthy sibling relationships.
Choice D rationale:
Avoiding having the sibling visit the child in the facility may prevent the sibling from understanding the condition and create a sense of fear or confusion. Controlled, supervised visits can actually be beneficial, as they allow the siblings to interact and support each other in a safe environment.
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