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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. While additional staffing might be necessary, the nurse's priority in a mass casualty event is to assess and provide care to incoming clients.
B. Discharging specific acute care clients may not be the immediate priority in a mass casualty event.
C. Correct. In a mass casualty event, the nurse should collaborate with the emergency department to determine the medical needs and prioritize care for incoming clients.
D. Acting as a liaison between the facility and the media may not be the immediate priority during a mass casualty event.

A. Current medications B. Temperature C. Hemoglobin and hematocrit D. WBC count E. Blood pressure F. Respiratory rate G. Stool results H. Heart rate

Correct Answer is ["A","C","E","G","H"]

Explanation

The correct answer is:Choices c, e, g, h, and a.

Choice A rationale (Current medications): The client is taking Ibuprofen 800 mg three times daily as needed for arthritis pain.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation, ulcers, and bleeding, especially when used at high doses or for a prolonged period 1 2. Given the client’s symptoms of abdominal pain and a history of dark, tarry stool, the medication could be contributing to these symptoms and warrants further investigation.

Choice B rationale (Temperature): The client’s temperature is 37.5° C (99.5° F), which is within the normal range 3 4. Therefore, it does not require immediate follow-up.

Choice C rationale (Hemoglobin and hematocrit): The client’s hemoglobin level is 9.1 g/dL, which is lower than the normal range of about 13.0 to 17.5 g/dL for adult males and 12.0 to 15.5 g/dL for adult females 5 6.The client’s hematocrit is 27%, which is also lower than the normal range of about 38.3% to 48.6% for adult males and 35.5% to 44.9% for adult females 7.Low hemoglobin and hematocrit levels can indicate anemia, which could explain the client’s reported fatigue and pale mucous membranes 8 7.

Choice D rationale (WBC count): The client’s WBC count is 6,700/mm3, which falls within the normal range of about 4,500 to 11,000 WBCs per microliter 9 10. Therefore, it does not require immediate follow-up.

Choice E rationale (Blood pressure): The client’s blood pressure is 90/50 mm Hg, which is lower than the normal range 11. Low blood pressure can cause symptoms such as dizziness, fainting, or blurred vision and requires immediate follow-up.

Choice F rationale (Respiratory rate): The client’s respiratory rate is 18 breaths per minute, which is within the normal range for adults of about 12 to 20 breaths per minute 4 12. Therefore, it does not require immediate follow-up.

Choice G rationale (Stool results): The client’s stool tested positive for blood (Hemoccult positive), which could indicate gastrointestinal bleeding 13. This finding, combined with the client’s reported abdominal pain and history of dark, tarry stool, requires immediate follow-up.

Choice H rationale (Heart rate): The client’s heart rate is 118 beats per minute, which is higher than the normal range for adults of about 60 to 100 beats per minute 14.A high heart rate, or tachycardia, can be caused by factors such as stress, anxiety, physical exertion, dehydration, and certain medical conditions 14. Given the client’s reported symptoms and medical history, this finding warrants immediate follow-up.

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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

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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Correct Answer is ["A","C","E","G","H"]

Explanation

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