A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
Pale and a 24-hr fluid deficit of 30 mL
Sunken fontanels and dry mucous membranes
Temperature 38°C (100.4°F) and pulse rate 124/min
Decreased appetite and irritability
The Correct Answer is B
A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.
B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.
C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.
D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Measuring gastric residual volumes every 4 hours is important to assess gastric emptying and to determine if the client can tolerate the feedings. If residuals are high, it may indicate delayed gastric emptying and the need to adjust the feeding rate.
B. Incorrect. While flushing the NG tube before and after medications is important to maintain patency, it is typically done with sterile water, not sodium chloride, unless otherwise specified by a protocol. Therefore, this statement may not be fully accurate.
C. Incorrect. The head of the bed should be elevated to a 30-45° angle to help prevent aspiration during enteral feedings.
D. Incorrect. The rate of the feeding should be advanced gradually to prevent overloading the client's gastrointestinal tract. This does not involve advancing the rate every 2 hours.
Correct Answer is B
Explanation
A. Incorrect. Absence seizures typically do not have an aura. They are characterized by a sudden and brief loss of awareness without warning.
B. Correct. Absence seizures often involve a brief period of staring and decreased responsiveness. They can indeed be mistaken for daydreaming, as they are not as dramatic as other types of seizures.
C. Incorrect. Absence seizures are usually very brief, lasting only a few seconds (often less than 10 seconds), rather than 30 to 60 seconds.
D. Incorrect. Absence seizures have a sudden and abrupt onset, not a gradual one. They occur without warning and without a preceding aura.
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