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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Biological response modifiers (e.g., TNF inhibitors) help manage RA by modifying immune responses, but they increase the risk of infection, not prevent it.
B. Cold therapy should not be applied directly to the skin—it should be wrapped in a towel to prevent skin damage. Cold therapy is used for acute inflammation, not stiffness.
C. Heat therapy, such as a hot shower or warm compress, helps reduce morning stiffness and joint pain in clients with rheumatoid arthritis (RA).
D. Clustered activity can lead to fatigue. Instead, activities should be spread out with rest periods.

A. Polyuria B. Hematuria C. Weight loss D. Hypotension

Correct Answer is B

Explanation

A. Incorrect – Oliguria (decreased urine output), not polyuria, is expected due to kidney inflammation.
B. Correct – Hematuria (blood in urine) is a hallmark sign due to glomerular damage. Urine may appear tea- or cola-colored.
C. Incorrect – Weight gain is expected due to fluid retention, not weight loss.
D. Incorrect – Hypertension (not hypotension) occurs due to fluid overload and sodium retention.

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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?

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