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1. Question
A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?
Correct
Option C is the correct answer:
Rationale: Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.003 to 1.030, urine output of at least 1 mL/kg/hr, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hr, a specific gravity of 1.035, and no tears would indicate that the deficit is not resolving.
Test-Taking Strategy: Focus on the subject, assessment findings indicating that fluid volume deficit is resolving. Recall the parameters that indicate adequate hydration status. The only option that indicates an improving fluid balance is option 3. The other options indicate fluid imbalance.
Incorrect
Option C is the correct answer:
Rationale: Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.003 to 1.030, urine output of at least 1 mL/kg/hr, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hr, a specific gravity of 1.035, and no tears would indicate that the deficit is not resolving.
Test-Taking Strategy: Focus on the subject, assessment findings indicating that fluid volume deficit is resolving. Recall the parameters that indicate adequate hydration status. The only option that indicates an improving fluid balance is option 3. The other options indicate fluid imbalance.
Fluid volume deficit (FVD) occurs when loss of extracellular fluid volume exceeds the intake of fluid. It occurs when water and electrolytes are lost in the same proportion as they exist in normal body fluids, so that the ratio of serum electrolytes to water remains the same. Fluid volume deficit (hypovolemia) should not be confused with the term
dehydration, which refers to loss of water alone with increased serum sodium levels. FVD may occur alone or in combination with other imbalances. Unless other imbalances are present concurrently, serum electrolyte concentrations remain essentially unchanged.
