PEDIATRIC HESI CASE STUDY: DEHYDRATION
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. - CORRECT 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?" - CORRECT
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
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. - CORRECT 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?" - CORRECT
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
