The nurse cares for a child admitted with severe dehydration secondary to gastroenteritis. Which assessment data would be most reliable in determining the client's response to the prescribed intravenous fluid replacement?
The nurse cares for a child admitted with severe dehydration secondary to gastroenteritis. Which assessment data would be most reliable in determining the client's response to the prescribed intravenous fluid replacement?
A. The number of stools in the past shift
[4%]
B. The current weight compared to the admission weight
[34%]
C. Mucous membrane assessment
[25%]
D. The 24-hour urinary output
[38%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Gastrointestinal
Client Need
Test Plan
Pharmacological and Parenteral Therapies
Related Topic
Expected Actions/Outcomes
Item Type
Item Type
Analysis
Explanation
Choice B is correct. Weight is the gold standard in determining fluid status. It provides an objective assessment of the client's overall fluid status. As a reminder, One kilogram equals 2.2 pounds, equivalent to one liter of fluid. If the client has an increase in one kilogram, compared to their admission weight, they have responded favorably to the fluid replacement.
Choice A is incorrect. The intravenous fluid replacement does not impact the number of stools, which would have no relevance to a client's fluid status about the prescribed IV fluids. If the client were prescribed medication such as loperamide to decrease their stooling, that would be an effective measure. However, the IV fluids and the number of stools the client creates have no relationship.
Choice C is incorrect. Mucous membrane assessment will help determine if a client has dehydration (dry oral cavity, sunken eye appearance). However, this assessment data is less objective than a client gaining weight.
Choice D is incorrect. Urinary output is a helpful tool in determining fluid status but is not as accurate as weight. Medications and neuroendocrine factors can influence urinary output, even in individuals well hydrated. Thus, weight is the gold standard in determining fluid status.
Related Videos
2 Key Topics
Fluid Volume Deficit
5.7 Fluid Volume Imbalances
Additional Info
✓ For illnesses that may cause dehydration, the client must consume water-rich foods.
✓ Melons, cucumbers, tomatoes, and celery are products dense in water.
✓ The client should avoid foods rich in sugar, caffeine, and sodium, which would further cause dehydration.
