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 A
Explanation
Choice A rationale:
Correct Answer. Placing the medication along the side of the child's tongue is a recommended technique for administering oral medication to infants. This helps prevent the infant from spitting out the medication and encourages swallowing. Placing the medication directly on the center of the tongue might trigger the gag reflex.
Choice B rationale:
Putting small bits of ice on the child's tongue prior to administering the medication is not a standard technique and is not necessary for giving liquid medication. This could potentially create discomfort for the infant and may not contribute to effective medication administration.
Choice C rationale:
Positioning the child on their back during administration of the medication is not ideal. This position might increase the risk of choking. Placing the child in an upright or slightly inclined position is generally recommended to aid in swallowing and prevent choking.
Choice D rationale:
Adding the medication to the child's formula prior to feeding is not advisable without consulting a healthcare provider. Mixing medication with formula can alter the medication's effectiveness or interactions. It's important to administer medications separately from formula to ensure accurate dosing. The correct answer is choice C. Document the infant's respiratory rate every 2 hr. The correct answer is choice D. Adopted. The correct answer is choice A. "You should place the medication along the side of your child's tongue during administration."
Correct Answer is A
Explanation
Choice A rationale:
After a tonic-clonic seizure, it's common for the person to inadvertently bite their tongue, cheeks, or lips during the convulsive movements. Checking the mouth for any signs of bleeding or injuries is essential to ensure the person's safety and provide appropriate care.
Choice B rationale:
Placing the child's head in a hyperextended position is not recommended after a seizure. In fact, it's important to keep the person's head and neck in a neutral position to prevent potential injury. Hyperextending the neck could lead to strain or other complications.
Choice C rationale:
Giving the child a drink of water immediately after a seizure is not necessary and might be unsafe. The child may still be disoriented or have difficulty swallowing immediately after the seizure. It's best to ensure the child's safety and monitor their condition before offering any fluids.
Choice D rationale:
Administering naloxone intramuscularly is not indicated for a tonic-clonic seizure. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose. Seizures have a different underlying cause, and administering naloxone would not be effective or appropriate in this context.
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