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","D","G"]
Explanation
Based on the provided information, the nurse should include the following statements in the client's teaching:
C. "Wear loose-fitting clothing": This is because the specific gravity of the urine is slightly elevated (1.022), which may indicate mild dehydration. Loose-fitting clothing can help promote comfort and ventilation, especially in cases of dehydration.
D. "Wear flat or low-heeled shoes": There is no specific indication related to the urine dipstick results, but it is generally good advice for maintaining proper foot health and preventing strain on the feet and ankles.
G. "You should avoid fried foods": There are no specific indications related to the urine dipstick results, but a healthy diet is always beneficial for overall well-being. Avoiding fried foods can be a part of a balanced diet and promote better health.
The following statements should not be included in the client's teaching based on the provided urine dipstick results:
A. "Try using an abdominal support belt": There is no indication related to the urine dipstick results that suggests the need for an abdominal support belt.
B. "Take hot showers to help relieve itching": Itching is not mentioned in the urine dipstick results, so there is no specific indication to recommend hot showers for this purpose.
E. "You can douche twice weekly": Douche is not related to urine dipstick results, and douching is generally not recommended as it can disrupt the natural balance of vaginal flora and may cause more harm than good.
F. "Eat two large meals a day": There is no indication related to the urine dipstick results that suggests a specific meal plan, and eating two large meals a day may not be suitable for everyone's dietary needs.
It's important for the nurse to provide teaching based on the client's specific needs and health conditions. In this case, the nurse can focus on maintaining hydration (based on the specific gravity result) and promoting a balanced diet and healthy lifestyle. Always individualize teaching based on the client's health status and any specific concerns they may have.
Correct Answer is D
Explanation
Given the older client's history of heart failure and current diagnosis of influenza, it is important for the nurse to ensure that appropriate infection control measures are being followed while providing care. In this scenario, the nurse observes the UAP wearing a gown and gloves to assist the client with sitting up to eat lunch. The nurse should review the need for the UAP to wear a face mask while in close contact with the client. Influenza is spread through respiratory droplets, so wearing a face mask is an important infection control measure to prevent the spread of the virus.
Reminding the UAP to apply a fitted respirator mask before entering the client's room may not be necessary in this situation, as a regular face mask may be sufficient for preventing the spread of influenza.
Additionally, the nurse should instruct the UAP to notify the nurse of any changes in the client's respiratory status. This will allow the nurse to monitor the client's condition closely and intervene promptly if needed.
Assigning the UAP to provide care for another client and assuming full care of the client may not be necessary, as long as appropriate infection control measures are being followed.
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