A nurse is caring for an infant who has gastroenteritis.
Which of the following assessment findings should the nurse report to the provider?
Sunken fontanels and dry mucous membranes.
Temperature 38° C (100.4° F) and pulse rate 124/min.
Decreased appetite and irritability.
Pale and a 24-hr fluid deficit of 30 mL.
The Correct Answer is A
These are signs of severe dehydration in an infant, which can be life-threatening and should be reported to the provider immediately. The infant may need intravenous fluids and electrolytes to restore hydration and prevent complications.
Choice B is wrong because a temperature of 38° C (100.4° F) and a pulse rate of 124/min are not abnormal for an infant and do not indicate severe dehydration. These are common findings in an infant who has gastroenteritis, which is an inflammation of the stomach and intestines caused by a virus, bacteria, or parasite.
Choice C is wrong because decreased appetite and irritability are also common findings in an infant who has gastroenteritis, but they do not indicate severe dehydration. The nurse should encourage oral rehydration with fluids such as breast milk, formula, or oral electrolyte solution.
Choice D is wrong because pale skin and a 24-hr fluid deficit of 30 mL are not signs of severe dehydration in an infant.
A fluid deficit of 30 mL is less than 1 oz and is not significant for an infant who weighs about 10 kg (22 lbs). A fluid deficit of more than 10% of body weight would indicate severe dehydration.
Normal ranges for vital signs in infants are as follows:
• Temperature: 36.5° C to 37.5° C (97.7° F to 99.5° F)
• Pulse rate: 100 to 160/min
• Respiratory rate: 30 to 60/min
• Blood pressure: 65/41 to 100/50 mm Hg
Normal ranges for fluid intake and output in infants are as follows:
• Fluid intake: 100 to 150 mL/kg/day
• Fluid output: 1 to 2 mL/kg/hr
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement shows respect for the client’s spirituality and offers support without imposing the nurse’s beliefs or values. Spirituality focuses on the significance and purpose of life and can help clients cope with depression and terminal illness.
Choice B is wrong because it implies that the client needs medication to deal with their feelings, which can be dismissive and insensitive.
Antianxiety medication may be appropriate for some clients, but it should not be the first option.
Choice C is wrong because it assumes that the client is ready to discuss advance directives, which may not be the case.
Advance directives are legal documents that specify the client’s wishes for end-of-life care, such as resuscitation, organ donation, or power of attorney.
The nurse should assess the client’s readiness and understanding before initiating this conversation.
Choice D is wrong because it suggests that the client is close to death and needs hospice care, which can be discouraging and frightening. Hospice care is an interdisciplinary team effort that provides palliative care for clients who have a terminal illness and a life expectancy of less than 6 months.
The nurse should explain the benefits of hospice care and obtain the client’s consent before making a referral.
Correct Answer is A
Explanation
This statement shows respect for the client’s interest in alternative therapies and offers guidance on how to choose a reliable and qualified provider. Alternative therapies can provide some benefits for people with rheumatoid arthritis, such as reducing pain, inflammation, and stiffness, but they should be used as a complement to conventional treatments and not as a substitute.
Choice B is wrong because it implies that the client has no role in deciding their own treatment plan and that alternative therapies are not worth considering.
This may discourage the client from sharing their preferences and concerns with the provider.
Choice C is wrong because it suggests that online support groups are a reliable source of information about alternative remedies, which may not be true.
Online sources may contain inaccurate, misleading, or harmful information that could jeopardize the client’s health and safety.
Choice D is wrong because it encourages the client to try any therapy that fits their personal belief system, without considering the evidence, effectiveness, or potential risks of such therapies. Some alternative therapies may interact with medications, cause side effects, or worsen the condition.
Normal ranges for rheumatoid arthritis are not applicable to this question, as it is not asking about laboratory values or disease activity measures. However, some common tests used to diagnose and monitor rheumatoid arthritis include erythrocyte sedimentation rate (ESR), C- reactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and joint ultrasound or X-ray.
The normal ranges for these tests may vary depending on the laboratory and the method used.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today