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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. A client with a sealed radiation implant requires strict precautions and monitoring, making them unsuitable for early discharge.
B. A client with COPD and a respiratory rate of 44/min is unstable and requires close monitoring.
C. A client on heparin for deep vein thrombosis (DVT) requires continued monitoring due to the risk of embolism.
D. A client 1 day postoperative after a vertebroplasty is typically stable and may be discharged with instructions for at-home care.

A. Tell the client, "You seem to be very upset." B. Initiate seclusion protocol. C. Engage the panic alarm. D. Use a face shield with a mask when providing care to the client.

Correct Answer is A

Explanation

A. Correct – Using therapeutic communication by acknowledging the client’s feelings can help de-escalate agitation.
B. Incorrect – Seclusion is a last resort and should only be used if the client poses an imminent threat.
C. Incorrect – The panic alarm should only be activated if the situation becomes physically dangerous.
D. Incorrect – A face shield with a mask is not necessary unless there is a risk of spitting or respiratory infection.

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A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

Nursing Test Bank

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