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
Encouraging progressive activity is generally beneficial for children with various health conditions, but it is not the primary focus for a child with polycythemia caused by a congenital heart disorder. The main concern is managing the increased blood viscosity and preventing complications related to it.
Choice B rationale
Expecting the skin to turn yellow is not a typical symptom of polycythemia. Jaundice is more commonly associated with liver conditions or hemolytic diseases, not polycythemia caused by congenital heart disorders.
Choice C rationale
Preparing for seizures is not directly related to polycythemia. Seizures are more commonly associated with neurological conditions or severe electrolyte imbalances, not polycythemia.
Choice D rationale
Preventing dehydration is crucial for children with polycythemia because dehydration can increase blood viscosity, leading to a higher risk of thrombotic events. Ensuring adequate hydration helps maintain proper blood flow and reduces the risk of complications.
Correct Answer is B
Explanation
Choice A rationale
Montelukast is a leukotriene receptor antagonist used for long-term control and prevention of asthma symptoms. It is not a rescue medication and does not provide immediate relief during an acute asthma attack. Montelukast works by reducing inflammation and preventing bronchoconstriction, but its effects are not rapid enough to address the immediate needs of a patient experiencing an acute asthma attack.
Choice B rationale
Albuterol is a short-acting beta-agonist (SABA) that provides rapid bronchodilation and is the first-line treatment for acute asthma attacks. It works by relaxing the smooth muscles in the airways, leading to quick relief of bronchospasm and improved airflow. Administering albuterol promptly can help alleviate symptoms and prevent the progression of an asthma attack, making it the priority medication in this scenario.
Choice C rationale
Fluticasone is an inhaled corticosteroid used for long-term control of asthma. It helps reduce inflammation in the airways and prevent asthma symptoms but is not effective as a rescue medication during an acute asthma attack. Inhaled corticosteroids are typically used as part of a daily maintenance regimen to manage chronic asthma and prevent exacerbations.
Choice D rationale
Budesonide is another inhaled corticosteroid used for long-term asthma control. Like fluticasone, it helps reduce airway inflammation and prevent asthma symptoms but is not suitable for immediate relief during an acute asthma attack. Inhaled corticosteroids are important for managing chronic asthma but do not provide the rapid bronchodilation needed in an emergency situation.