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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 C

Explanation

Choice A rationale

Distended neck veins are not a typical manifestation of pyloric stenosis. This condition primarily affects the gastrointestinal system, leading to symptoms related to feeding and digestion rather than cardiovascular symptoms like distended neck veins.

Choice B rationale

Red currant jelly stools are associated with intussusception, not pyloric stenosis. Intussusception involves the telescoping of one part of the intestine into another, leading to obstruction and the characteristic stool appearance.

Choice C rationale

Projectile vomiting is a hallmark symptom of pyloric stenosis. This occurs due to the obstruction at the pylorus, which prevents food from passing into the small intestine, leading to forceful expulsion of stomach contents.

Choice D rationale

A ridged abdomen is not a typical symptom of pyloric stenosis. While the abdomen may be distended due to the obstruction, the primary symptom is projectile vomiting.

Correct Answer is C

Explanation

Choice A rationale

Regular insulin should not be withheld during illness. When a person with type 1 diabetes is sick, their body may produce more glucose due to stress and infection, leading to hyperglycemia. Therefore, it is crucial to continue taking insulin to manage blood glucose levels effectively.

Choice B rationale

Insulin should not be stored in the freezer. Freezing insulin can cause it to degrade and lose its effectiveness. Insulin should be stored in the refrigerator at a temperature between 2°C and 8°C (36°F and 46°F) until it is opened. Once opened, it can be kept at room temperature for a specified period, usually around 28 days.

Choice C rationale


The target range for morning blood glucose levels in children with type 1 diabetes is typically between 90 and 130 mg/dL. Maintaining blood glucose within this range helps to prevent both hyperglycemia and hypoglycemia, ensuring better overall diabetes management and reducing the risk of complications.

Choice D rationale

Eating a snack before physical activity is important for children with type 1 diabetes to prevent hypoglycemia. Physical activity can lower blood glucose levels, so having a snack that contains carbohydrates can help maintain stable blood glucose levels during exercise.

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