A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?

Respiratory rate 24/min>

Urine specific gravity 1.015

Heart rate 130/min

Capillary refill greater than 3 seconds

Answer and Explanation

The Correct Answer is B

A. Respiratory rate 24/min: While a normal respiratory rate is positive, it is not a primary marker of hydration status.
B. Urine specific gravity 1.015: A normal urine specific gravity indicates adequate hydration.
C. Heart rate 130/min: Tachycardia indicates ongoing dehydration or stress.
D. Capillary refill greater than 3 seconds: Prolonged capillary refill suggests inadequate perfusion and continued dehydration.

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Correct Answer is ["A","B","D"]

Explanation

A. Wheezing: Reflux of stomach contents can cause aspiration, leading to wheezing or respiratory symptoms.
B. Weight Loss: Chronic vomiting and poor feeding due to GER can result in inadequate weight gain or weight loss.
C. Pallor: Pallor is not commonly associated with GER but may indicate anemia or another condition.
D. Vomiting: Vomiting, especially after feeding, is a hallmark sign of GER.
E. Rigid Abdomen: A rigid abdomen is more indicative of severe abdominal pathology like peritonitis, not GER.

A. Feed the infant half-strength formula for the first 48 hr. B. Remove elbow restraints while the infant is sleeping. C. Administer pain medication PRN for the first 48 hr. D. Keep the infant in a side-lying position.

Correct Answer is D

Explanation

A. Feed the infant half-strength formula for the first 48 hr: Feeding guidelines do not typically require diluted formula unless directed by the surgeon.
B. Remove elbow restraints while the infant is sleeping: Elbow restraints should remain in place to prevent the infant from touching the surgical site, even during sleep.
C. Administer pain medication PRN for the first 48 hr: Pain medication should be administered on a regular schedule initially to control pain effectively.
D. Keep the infant in a side-lying position: This position helps protect the surgical site and minimizes the risk of aspiration.

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A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?

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Naxlex Comprehensive Predictor Exams

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