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A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

A.

Blood pressure.

B.

Respiratory rate.

C.

Body weight.

D.

Skin integrity.

Answer and Explanation

The Correct Answer is C

Choice A rationale

 

Blood pressure is not the most reliable indicator of fluid loss in infants. Blood pressure can remain normal until dehydration is severe.

 

Choice B rationale

 

Respiratory rate can be affected by many factors and is not the most reliable indicator of fluid loss.

 

Choice C rationale

 

Body weight is the most reliable indicator of fluid loss in infants. A significant decrease in body weight indicates significant fluid loss and helps guide appropriate fluid replacement therapy.

 

Choice D rationale

 

Skin integrity can be affected by many factors and is not the most reliable indicator of fluid loss.


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View Related questions

Correct Answer is B

Explanation

Choice A rationale

Isosorbide dinitrate is a nitrate used to treat angina and heart failure. It does not have contraindications for patients with asthma.

Choice B rationale

Carvedilol is a beta-blocker that can exacerbate asthma symptoms because it blocks beta-2 receptors in the lungs, leading to bronchoconstriction.

Choice C rationale

Captopril is an ACE inhibitor used to treat hypertension and heart failure. It does not have contraindications for patients with asthma.

Choice D rationale

Fluticasone is a corticosteroid used to manage asthma and does not have contraindications for patients with heart failure.

Correct Answer is B

Explanation

Choice A rationale

Giving an oral rehydration solution is not appropriate without first assessing the infant. Projectile vomiting in a 2-month-old could indicate a serious condition such as pyloric stenosis, which requires medical evaluation.

Choice B rationale

Bringing the baby to the clinic today is the appropriate response. Projectile vomiting in an infant can be a sign of a serious condition that requires prompt medical evaluation and treatment.

Choice C rationale

Switching to a different formula is not appropriate without first assessing the infant. Projectile vomiting could indicate a serious condition that needs to be evaluated by a healthcare provider.

Choice D rationale

Burping the baby more frequently during feedings may help with minor feeding issues, but it is not appropriate advice for projectile vomiting. The infant needs to be evaluated by a healthcare provider to determine the cause of the vomiting.

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