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

Choice A rationale:

Hearing loss is not a typical sign of digoxin toxicity. Digoxin toxicity primarily affects the visual system, leading to disturbances such as blurred or yellow-tinted vision. It can also cause various cardiac symptoms due to its effects on heart rhythm and contractility. Hearing loss is not a recognized symptom of digoxin toxicity.

Choice B rationale:

Tachycardia (fast heart rate) can be a sign of digoxin toxicity. Digoxin can cause arrhythmias and alter heart rate, which may lead to tachycardia. While this is a possible symptom, it is not as specific as other manifestations, such as visual disturbances.

Choice C rationale:

Blurred vision is a hallmark sign of digoxin toxicity. Digoxin can cause disturbances in color vision, such as seeing yellow or green halos around objects. Blurred vision is a significant indicator of digoxin toxicity and requires prompt medical attention.

Choice D rationale:

Insomnia is not a recognized symptom of digoxin toxicity. Digoxin toxicity primarily affects the cardiovascular and visual systems, leading to symptoms related to heart rhythm disturbances and vision changes. Insomnia is not a typical manifestation of digoxin toxicity.

A. Family history of malignant hypertension B. Chronic obstructive pulmonary disease C. Hip arthroplasty 1 week ago D. Acute renal failure 6 months ago

Correct Answer is C

Explanation

A. Incorrect. Family history of malignant hypertension is not a contraindication for alteplase.

B. Incorrect. COPD itself is not a contraindication for alteplase. While it can complicate overall management, it does not increase the immediate risk of bleeding associated with thrombolytics.

C. Correct. Recent surgery, especially orthopedic surgery like hip arthroplasty, is a contraindication for thrombolytic therapy due to the increased risk of bleeding and hematoma formation at the surgical site.

D. Incorrect. Acute renal failure from six months ago is not a contraindication for alteplase.

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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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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking digoxin to treat chronic heart failure.Which of the following findings should indicate to the nurse that the client is developing digoxin toxicity?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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