A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?
Respiratory rate of 24 breaths/min
Heart rate of 130/min
Urine specific gravity of 1.015
Capillary refill of greater than 3 seconds
The Correct Answer is C
Choice A reason: A respiratory rate of 24 breaths/min is within the normal range for a 3-year-old child. It does not indicate the degree of hydration or dehydration of the child.
Choice B reason: A heart rate of 130/min is above the normal range for a 3-year-old child, which is 80 to 120/min. It may indicate dehydration, fever, pain, or anxiety. It does not indicate the effectiveness of oral rehydration therapy.
Choice C reason: A urine specific gravity of 1.015 is within the normal range for a child, which is 1.005 to 1.030. It indicates that the child's urine is adequately concentrated and that the child is well hydrated. It is a reliable indicator of the effectiveness of oral rehydration therapy.

Choice D reason: A capillary refill of greater than 3 seconds is abnormal and indicates poor peripheral perfusion. It may be a sign of dehydration, shock, or hypothermia. It does not indicate the effectiveness of oral rehydration therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Rice is a suitable food choice for a child who has celiac disease, as it is a gluten-free grain that does not cause inflammation or damage to the small intestine. Rice can provide carbohydrates, fiber, and vitamins for the child's nutrition.
Choice B reason: Rye is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Rye can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
Choice C reason: Wheat is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Wheat can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
Choice D reason: Barley is not a good food choice for a child who has celiac disease, as it is a gluten-containing grain that can trigger an immune response and harm the small intestine. Barley can cause symptoms such as diarrhea, abdominal pain, bloating, and weight loss in the child.
Correct Answer is C
Explanation
Choice A reason: Promising not to tell anyone about the abuse is not a helpful statement, as it implies that the abuse is a secret that should be hidden. This may make the child feel ashamed, guilty, or isolated. The nurse has a duty to report the abuse to the proper authorities and to protect the child from further harm.
Choice B reason: Blaming the family for the abuse is not a helpful statement, as it may cause the child to feel conflicted, angry, or fearful. The child may still love the family member who abused them, or may depend on them for their basic needs. The nurse should avoid making judgments or accusations, and instead focus on the child's feelings and safety.
Choice C reason: Reassuring the child that the abuse is not their fault is a helpful statement, as it may help the child cope with the trauma and reduce the feelings of self-blame, guilt, or shame. The nurse should validate the child's emotions and let them know that they are not responsible for the abuse or for stopping it.
Choice D reason: Suggesting to discuss the abuse with the family is not a helpful statement, as it may put the child in danger or cause them more distress. The child may not feel comfortable or safe to talk about the abuse with the family member who abused them, or with other family members who may not believe them or support them. The nurse should respect the child's privacy and boundaries, and only involve the family with the child's consent and under professional guidance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
