A nurse is caring for an infant who has rotavirus. Which of the following findings indicates that the infant is moderately dehydrated?
Respiratory rate 28/min
Capillary refill 1 second
Weight loss 7%
Bradycardia
The Correct Answer is A
A. A respiratory rate of 28 breaths per minute indicates increased respiratory effort, which can be a sign of moderate dehydration. The infant may be trying to compensate for fluid
loss.
B. Capillary refill of 1 second is within the normal range (less than 2 seconds). It is not indicative of moderate dehydration.
C. Weight loss of 7% is a significant amount of weight loss and is indicative of severe dehydration, not moderate dehydration. Moderate dehydration is usually defined as 5- 10% weight loss.
D. Bradycardia (slow heart rate) is not typically associated with dehydration. In fact, tachycardia (fast heart rate) is a more common sign of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.
B. Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.
C. While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of
treatment. It takes longer for the viral load to decrease significantly.
D. Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may be
individualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.
Correct Answer is B
Explanation
A. Eating a large amount of food one day and very little the next is a normal eating pattern for toddlers. They may have days when they eat more and days when they eat less.
B. This finding should be reported to the provider. Breath-holding spells during temper tantrums can be concerning and may require further evaluation.
C. Toddlers typically need about 11-14 hours of sleep per day, so sleeping 11 to 12 hours is within the normal range.
D. A vocabulary of 30 words is considered normal for a 24-month-old toddler.
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