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
Decreased appetite and irritability
Temperature 38° C (100.4° F) and pulse rate 124/min
Sunken fontanels and dry mucous membranes
The Correct Answer is D
A. Incorrect – A 24-hour fluid deficit of 30 mL is mild and does not require immediate intervention.
B. Incorrect – Decreased appetite and irritability are common with gastroenteritis but not as concerning as dehydration.
C. Incorrect – A temperature of 38°C (100.4°F) and pulse of 124/min are mild and expected with infection.
D. Correct – Sunken fontanels and dry mucous membranes are signs of dehydration, which is a major concern in gastroenteritis. Severe dehydration can lead to hypovolemic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect – Diminished breath sounds are not a primary sign of hemorrhage after a tonsillectomy.
B. Incorrect – Increased drowsiness could be due to pain medication or anesthesia effects, not necessarily hemorrhage.
C. Correct – Frequent swallowing is a classic sign of post-tonsillectomy bleeding because the child may be swallowing blood. The nurse should assess for bleeding immediately.
D. Incorrect – Elevated pain level is expected postoperatively but does not specifically indicate hemorrhage.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Hypercapnia: Malignant Hyperthermia
Malignant hyperthermia (MH) is a life-threatening reaction to anesthesia, causing uncontrolled muscle metabolism and CO₂ buildup.
Wheezes: Latex Allergy
A latex allergy can trigger anaphylaxis, leading to airway swelling and bronchospasm, which cause wheezing.
Tachycardia: Malignant Hyperthermia, Latex Allergy, Hypovolemic Shock
Tachycardia is a common response to stress, hypoxia, allergic reactions, or shock.
MH: Increased metabolism causes hyperthermia and tachycardia.
Latex Allergy: Anaphylaxis can cause vasodilation and compensatory tachycardia.
Hypovolemic Shock: The body compensates for low blood volume by increasing heart rate.
Muscle Rigidity: Malignant Hyperthermia
A hallmark sign of MH is generalized muscle rigidity, especially in the jaw and chest, due to sustained muscle contractions.
Urticaria: Latex Allergy
Latex allergy causes histamine release, leading to itching, rash, and hives (urticaria).
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