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 B
Explanation
A. Decreased pain is not a direct effect of furosemide.
B. Furosemide is a diuretic that removes excess fluid, leading to weight loss. This is the best indicator of effectiveness.
C. Furosemide typically lowers blood pressure, not increases it.
D. Furosemide does not treat inflammation directly.
Correct Answer is B
Explanation
A. Mineral oil is a lubricant laxative that can interfere with fat-soluble vitamin absorption and is not recommended for long-term use.
B. Regular physical activity stimulates bowel motility, helping to prevent constipation caused by opioids.
C. Insoluble fiber should be increased, not decreased, as it helps add bulk to stool.
D. Clients should drink at least 2-3 L of fluids daily, not just 1.5 L, to promote bowel movement.
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