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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is a. Moving both crutches with the stronger leg forward first.
Rationale for Choice C:
- Proper positioning of the hands on the grips and keeping the elbows slightly flexed helps ensure stability and control while using the crutches.
Rationale for Other Choices:
a.In a three-point gait, the client moves both crutches and the affected leg together, followed by the unaffected leg. The stronger leg does not move forward first.
b. Stepping with the affected leg first when going up stairs: This action is incorrect for the three-point gait. When ascending stairs, the client should move the stronger leg up first, followed by the crutches and the affected leg.
d. Supporting his body weight while leaning on the axillary crutch pads: This action is also correct for general crutch use, but it does not specifically address the weight-bearing restrictions and movement pattern of the three-point gait.
Additional Information:
- Practice and supervision:It's essential for the client to practice the three-point gait under the supervision of a healthcare professional to ensure proper technique and safety.
- Gradual progression:The client should gradually increase their distance and duration of crutch use as their strength and coordination improve.
- Pain management:Adequate pain management is crucial to allow the client to participate in rehabilitation and regain mobility.
Correct Answer is A
Explanation
A. Correct. A filter needle should be used to withdraw medication from an ampule to prevent drawing up any glass fragments into the syringe.
B. Using the same needle to draw up and inject the client is not recommended to prevent contamination.
C. Breaking the neck of the ampule toward the body is not a safe practice, as it can cause injury.
D. Ampules should be disposed of properly in a sharps container, not a regular trash can.
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