Dehydration Hesi Case study
What assessment findings will lead the nurse to believe an infant is moderately
dehydrated?
A. Rectal temperature of 99°F (37.2°C), heart rate (HR) of 120 beats/minute, and a
respiratory rate of 28 breaths/minute.
B. A sunken fontanel, dry mucous membranes, and HR of 160 beats/minute.
C. Warm skin, rectal temperature of 100°F (37.8°C), and blood pressure 100/60
mmHg.
D. Two wet diapers within the past 8 hours, +3 edema of feet, and a respiratory
rate of 30 breaths/minute. - ANSWER-ANSWER (s): B
Rational:
- Common signs of dehydration in infants include a sunken fontanel, slow capillary
refill, dry mucous membranes, poor skin turgor, pale color, decreased urinary
output, normal to low blood pressure, and normal to high heart rate.
,To obtain more information about the client's current status, which questions are
a priority for the nurse to ask family? (Select all that apply. One, some, or all
options may be correct.)
A. "Do you have any other children?"
B. "Have you offered fluids other than formula?"
C. "What was the client's last weight?"
D. "Has the client completed all their immunizations?"
E. "How many hours does the client normally sleep each day?" - ANSWER-
ANSWER (s): B, C
Rational:
- If the infant is not taking formula, clear liquid replacement fluids can help to
maintain hydration.
- Weight is the most important determinant in fluid loss. The nurse needs baseline
data to compare to infants current condition inorder to determine hydration
status.
Lab Values
, - 137 meq/L (mmol/L)
Based on the client's lab values, which type of dehydration does the nurse
suspect?
A. Isonatremic
B. Hyponatremic
C. Hypernatremic
D. Hypokalemic - ANSWER-ANSWER (s): A
Rational:
Classification of dehydration, based on the serum sodium level 130 to 150 mEq/L
is Isonatremic meaning that sodium and water are lost in equal proportions.
What intravenous fluids does the nurse anticipate for initial rehydration?
A. Dextrose 5% in water at 25 mL/hour
B. Dextrose 5% lactated ringers as a 150 mL bolus over 30 minutes
C. Dextrose 5% in sodium chloride 0.9% + 20 meq KCL/L at 75 mL/hour
What assessment findings will lead the nurse to believe an infant is moderately
dehydrated?
A. Rectal temperature of 99°F (37.2°C), heart rate (HR) of 120 beats/minute, and a
respiratory rate of 28 breaths/minute.
B. A sunken fontanel, dry mucous membranes, and HR of 160 beats/minute.
C. Warm skin, rectal temperature of 100°F (37.8°C), and blood pressure 100/60
mmHg.
D. Two wet diapers within the past 8 hours, +3 edema of feet, and a respiratory
rate of 30 breaths/minute. - ANSWER-ANSWER (s): B
Rational:
- Common signs of dehydration in infants include a sunken fontanel, slow capillary
refill, dry mucous membranes, poor skin turgor, pale color, decreased urinary
output, normal to low blood pressure, and normal to high heart rate.
,To obtain more information about the client's current status, which questions are
a priority for the nurse to ask family? (Select all that apply. One, some, or all
options may be correct.)
A. "Do you have any other children?"
B. "Have you offered fluids other than formula?"
C. "What was the client's last weight?"
D. "Has the client completed all their immunizations?"
E. "How many hours does the client normally sleep each day?" - ANSWER-
ANSWER (s): B, C
Rational:
- If the infant is not taking formula, clear liquid replacement fluids can help to
maintain hydration.
- Weight is the most important determinant in fluid loss. The nurse needs baseline
data to compare to infants current condition inorder to determine hydration
status.
Lab Values
, - 137 meq/L (mmol/L)
Based on the client's lab values, which type of dehydration does the nurse
suspect?
A. Isonatremic
B. Hyponatremic
C. Hypernatremic
D. Hypokalemic - ANSWER-ANSWER (s): A
Rational:
Classification of dehydration, based on the serum sodium level 130 to 150 mEq/L
is Isonatremic meaning that sodium and water are lost in equal proportions.
What intravenous fluids does the nurse anticipate for initial rehydration?
A. Dextrose 5% in water at 25 mL/hour
B. Dextrose 5% lactated ringers as a 150 mL bolus over 30 minutes
C. Dextrose 5% in sodium chloride 0.9% + 20 meq KCL/L at 75 mL/hour
