A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Bulging anterior fontanel

Decreased temperature

Hypertension

Oliguria

Answer and Explanation

The Correct Answer is D

A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.

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Correct Answer is D

Explanation

A. Urinary output 120 mL/4 hr. This is on the lower end of normal but not critical. It should be monitored, especially in clients on opioids, but does not require immediate reporting ahead of more life-threatening findings.
B. Pupil diameter 6 mm. Dilated pupils may suggest other issues such as anxiety, medication effects, or pain, but are not a common concern with morphine, which usually causes miosis (pupil constriction). Still, this is not the most urgent concern.
C. Bowel movement 5 days ago. Constipation is a common side effect of opioids, including morphine, and should be addressed with stool softeners or laxatives. However, it is not an emergency.
D. Blood pressure 80/40 mm Hg. This indicates hypotension, a potentially life-threatening side effect of IV morphine, especially if it results in decreased perfusion or shock. It requires immediate intervention and provider notification.

A. Potential complications B. Cost of the procedure C. Possible alternative treatments D. Explanation of the procedure E. Expected outcome of the procedure

Correct Answer is ["A","C","D","E"]

Explanation

A. Potential complications. The provider is responsible for informing the client of possible risks and complications associated with the procedure. This ensures the client understands what to expect and can make an informed decision.
B. Cost of the procedure. While cost is an important consideration, it is not part of the informed consent process that the provider must explain. Financial discussions are typically handled by billing or administrative personnel.
C. Possible alternative treatments. Informed consent includes a discussion of reasonable alternatives so the client can weigh all available options. This allows for autonomous decision-making regarding their care.
D. Explanation of the procedure. The provider must describe the nature and details of the procedure, including what it involves and how it will be performed. This ensures the client understands what they are consenting to.
E. Expected outcome of the procedure. Clients should be informed of the anticipated results and benefits of the surgery. This helps set realistic expectations and supports informed decision-making.

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A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is receiving morphine IV for pain. Which of the following findings should the nurse report to the provider first?

Correct Answer is D

Explanation

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Correct Answer is ["A","C","D","E"]

Explanation

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