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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
Choice A rationale
A diastolic murmur is not a typical finding in coarctation of the aorta. This condition is more commonly associated with systolic murmurs.
Choice B rationale
Hypotension is not a common finding in coarctation of the aorta. In fact, hypertension in the upper extremities is more typical due to the narrowing of the aorta.
Choice C rationale
Excessive crying is not a specific indicator of coarctation of the aorta. It can be a symptom of many different conditions and is not diagnostic.
Choice D rationale
Unequal upper and lower extremity pulses are a key finding in coarctation of the aorta. The narrowing of the aorta causes reduced blood flow to the lower extremities, resulting in weaker pulses compared to the upper extremities.
Correct Answer is B
Explanation
Choice A rationale
Treating upper respiratory infections with over-the-counter medication is not recommended for children with sickle cell anemia. These children are at higher risk for infections and complications, and any signs of infection should be promptly evaluated by a healthcare provider.
Choice B rationale
Ensuring a consistent and daily intake of adequate fluids is crucial for preventing dehydration in children with sickle cell anemia. Dehydration can trigger a sickle cell crisis, leading to severe pain and other complications.
Choice C rationale
Avoiding immunizations is incorrect. Children with sickle cell anemia should receive all recommended vaccinations to prevent infections, which can be more severe in these children.
Choice D rationale
Suggesting that the child participate in sports activities without restriction is not advisable. Children with sickle cell anemia should avoid strenuous activities that can lead to dehydration and trigger a sickle cell crisis. .