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?
Blood pressure.
Respiratory rate.
Body weight.
Skin integrity.
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 A
Explanation
Choice A rationale
High fever is a common finding in children experiencing sickle cell crisis. The crisis is often triggered by infections, which can cause fever. The sickled red blood cells can block blood flow, leading to tissue ischemia and necrosis, which can also contribute to fever.
Choice B rationale
Bradycardia, or a slow heart rate, is not typically associated with sickle cell crisis. The crisis usually causes an increased heart rate due to pain and the body’s stress response.
Choice C rationale
Constipation is not a common finding in sickle cell crisis. The primary symptoms are related to pain and vaso-occlusion, which can cause severe pain and other complications.
Choice D rationale
Decreased respiratory rate is not a typical finding in sickle cell crisis. The crisis can cause respiratory distress due to pain and hypoxia, leading to an increased respiratory rate.
Correct Answer is D
Explanation
Choice A rationale
Encouraging the child to talk about the procedure is important for emotional support, but it is not the most critical assessment immediately after a cardiac catheterization. The priority is to monitor for potential complications.
Choice B rationale
Confirming to the child that the procedure has been completed is important for reassurance, but it is not the most critical assessment. The priority is to monitor for potential complications.
Choice C rationale
Gradually allowing the child to adapt to the lighted surroundings is not relevant to the immediate post-procedure care. The priority is to monitor for potential complications.
Choice D rationale
Checking pedal pulses frequently is the most important assessment after a cardiac catheterization via the femoral artery. It helps to ensure that there is adequate blood flow to the lower extremities and to detect any signs of arterial obstruction or complications at the catheter insertion site.