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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Correct Answer is D
Explanation
Choice A rationale
Taking pancreatic enzymes following meals is not effective. The enzymes need to be taken with meals to aid in the digestion of food as it is being consumed.
Choice B rationale
Pancreatic enzymes are not taken to improve metabolism. They are specifically prescribed to aid in the digestion of fats, proteins, and carbohydrates in children with cystic fibrosis.
Choice C rationale
Taking pancreatic enzymes 2 hours before meals is not effective. The enzymes need to be taken with meals to ensure they are present in the digestive tract when food is being digested.
Choice D rationale
Taking pancreatic enzymes helps digest the fat in foods. Children with cystic fibrosis have difficulty digesting fats due to the thick mucus that blocks the pancreatic ducts, preventing the release of digestive enzymes
Correct Answer is ["A","B","C","D"]
Explanation
A: This is the first step as it allows the nurse to gather information through observation without causing discomfort to the child. It involves looking at the child’s abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.
B: This step follows inspection to assess bowel sounds before any manipulation of the abdomen, which could alter the sounds. The nurse listens for the presence, frequency, and character of bowel sounds.
C:This step is performed to assess for tenderness, muscle tone, and surface characteristics. It is done gently to avoid causing pain or discomfort.
D:This is the final step to assess for any masses, organomegaly, or deep tenderness. It is performed more firmly but should be done carefully to avoid causing pain.