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 ["A","D","E"]
Explanation
Choice A rationale
The Measles, Mumps, and Rubella (MMR) vaccine is recommended for children at 12-15 months of age. This vaccine protects against three serious diseases: measles, mumps, and rubella. Measles can cause severe respiratory illness and encephalitis, mumps can lead to meningitis and hearing loss, and rubella can cause congenital rubella syndrome in unborn babies if a pregnant woman is infected.
Choice B rationale
The Rotavirus (RV) vaccine is typically given to infants at 2, 4, and sometimes 6 months of age. It is not recommended for children older than 8 months.
Choice C rationale
The Human Papillomavirus (HPV) vaccine is recommended for preteens starting at age 11 or 12. It is not given to 1-year-old children.
Choice D rationale
The Varicella (VAR) vaccine is recommended for children at 12-15 months of age to protect against chickenpox, which can cause severe skin infections, pneumonia, and encephalitis.
Choice E rationale
The Diphtheria, Tetanus, and Acellular Pertussis (DTaP) vaccine is part of the routine immunization schedule for children, with doses given at 2, 4, 6, and 15-18 months of age. This vaccine protects against three serious diseases: diphtheria, which can cause breathing problems and heart failure; tetanus, which can cause muscle stiffness and lockjaw; and pertussis (whooping cough), which can cause severe coughing spells and pneumonia.
Correct Answer is A
Explanation
Choice A rationale
Testing the urine for ketones is essential for managing type 1 diabetes, especially during illness. Ketones are produced when the body breaks down fat for energy due to insufficient insulin. High levels of ketones can lead to diabetic ketoacidosis, a serious condition that requires immediate medical attention.
Choice B rationale
While notifying the provider if blood glucose levels are over 350 mg/dL is important, it is not the most immediate action required during illness management. High blood glucose levels can indicate poor diabetes control, but ketone testing is more critical during illness to prevent ketoacidosis.
Choice C rationale
Withholding insulin when feeling nauseous is incorrect. Insulin should not be withheld during illness, as blood glucose levels can increase due to stress or infection. Continuing insulin administration is crucial to prevent hyperglycemia and ketoacidosis.
Choice D rationale
Limiting fluid intake during mealtime is not recommended. Proper hydration is essential for overall health and helps manage blood glucose levels. Fluids should be consumed as needed, especially during illness.