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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Nitroglycerin: Nitroglycerin is a vasodilator used primarily for angina and heart conditions, not enuresis.
B. Atenolol: Atenolol is a beta-blocker for hypertension or arrhythmias, not for enuresis.
C. Diltiazem: Diltiazem is a calcium channel blocker for cardiovascular conditions.
D. Desmopressin (DDAVP): This synthetic antidiuretic hormone reduces nighttime urine production, effectively treating enuresis.
Correct Answer is D
Explanation
A. Assess fluid balance: Although assessment is important, rehydration takes priority to address the acute loss of fluids and electrolytes.
B. Maintain fluid therapy: Fluid therapy maintenance is secondary to initiating rehydration.
C. Introduce a regular diet: Diet modification is less critical than rehydration in the acute phase.
D. Rehydrate: Rehydration addresses the immediate risk of dehydration and electrolyte imbalance caused by severe diarrhea.
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