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
A. Incorrect. Securing the tracheostomy tube with ties is important, but this is a task that should be performed by healthcare professionals initially. It is not typically part of discharge teaching.
B. Incorrect. Changing the tracheostomy dressing using clean technique is also an essential skill but may not be suitable for discharge teaching. The partner should be educated on monitoring the stoma site and recognizing signs of infection or complications.
C. Correct. Teaching the partner how to operate the portable suction machine is crucial for maintaining a patent airway. Suctioning is often necessary to clear mucus and secretions from the tracheostomy tube, especially when the client is at home.
D. Incorrect. Changing a tracheostomy tube, particularly a nondisposable one, is a procedure that should be performed by healthcare professionals due to the risk of complications and the need for sterile technique. It is not typically part of discharge teaching to non-medical caregivers.
Correct Answer is D
Explanation
As explained, holding the bottle directly over the sterile field can result in contamination. It's crucial to pour the solution from above or to the side of the sterile field, making sure the bottle doesn't touch the field or anything in the field. This minimizes the risk of contaminating the sterile setup.
If solution is spilled on the sterile field, that area is contaminated, and you cannot make it sterile again by covering it with gauze. The correct approach would be to discard the contaminated items and set up a new sterile field.
While it's important not to touch the label side of the bottle, this option doesn't address the action of placing the cap. The most important part of pouring a sterile solution is ensuring the cap stays sterile, which is what option D addresses.
When performing a sterile procedure, after removing the cap from a sterile bottle, the cap should be placed sterile-side up on a clean surface or a sterile field. This is because the sterile side of the cap should not touch any non-sterile surfaces, and placing it sterile-side up ensures it stays sterile.
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