A nurse is caring for a client with suspected viral gastroenteritis. What assessment finding should the nurse prioritize?
Skin turgor and mucous membranes
Blood pressure and heart rate
Urinary output and specific gravity
Respiratory rate and lung sounds
The Correct Answer is A
A) Correct. Skin turgor and mucous membranes are important indicators of hydration status, which is a critical concern in clients with gastroenteritis.
B) Incorrect. While blood pressure and heart rate are important vital signs, they may not provide immediate information about the client's hydration status.
C) Incorrect. Urinary output and specific gravity are important indicators of renal function, but they may not provide immediate information about the client's hydration status.
D) Incorrect. Respiratory rate and lung sounds are important assessments, but they may not provide immediate information about the client's hydration status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. Well water can become contaminated, especially during outbreaks, and is not inherently immune to contamination.
B) Correct. Boiling well water for at least one minute can help kill harmful microorganisms, making it safer to use during a gastroenteritis outbreak.
C) Incorrect. It is important to take precautions with well water during a gastroenteritis outbreak, as it can be a potential source of contamination.
D) Incorrect. Using well water directly from the source without any treatment can pose a risk of gastroenteritis if the water is contaminated.
Correct Answer is A
Explanation
A) Correct. Dry lips and a sunken fontanelle are signs of severe dehydration in an infant and require immediate attention.
B) Incorrect. While decreased urine output is a concern, it may not necessitate immediate reporting if it is only slightly decreased.
C) Incorrect. Mild irritability during feedings is a symptom of discomfort but may not necessitate immediate reporting.
D) Incorrect. Occasional vomiting after feeds is a common symptom of gastroenteritis and may not necessitate immediate reporting.
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