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
The Correct Answer is D
A. A small fluid deficit of 30 mL is not concerning unless it worsens or additional symptoms develop.
B. Decreased appetite and irritability can be expected with gastroenteritis and may not require immediate intervention.
C. A mild fever and increased pulse rate can be expected, but if these values remain stable and other signs of dehydration or worsening illness are absent, they do not require immediate intervention.
D. Sunken fontanels and dry mucous membranes are signs of dehydration and should be reported to the provider immediately.
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Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
A. Refuting delusions using logic can increase agitation and confusion. Instead, the nurse should offer reassurance and validation without arguing.
B. Giving the client one simple direction at a time helps minimize confusion and enhances the client’s
ability to follow instructions.
C. Establishing eye contact is important for communication and shows attentiveness, helping the client feel connected.
D. Allowing the client to choose among activities provides a sense of autonomy and can reduce agitation.
E. Reinforcing orientation helps maintain the client’s awareness of time, place, and person, which can reduce disorientation and anxiety.
Correct Answer is A
Explanation
A. This prescription is complete because it includes the medication name (Digoxin), the dosage (0.25 mg), the route (PO, meaning by mouth), and the frequency (daily). This is a fully clear and complete prescription.
B. This prescription is incomplete because it lacks the dosage for Cimetidine. The nurse cannot confirm the correct amount of the medication to administer without the dosage.
C. While the medication name, dosage (150 units/kg), and frequency (three times weekly) are included, the route is missing. Epoetin alfa can be given via different routes (subcutaneously or intravenously), so the route must be specified.
D. This prescription is incomplete because it lacks both the dosage form and the frequency. It states "200 mg PO," but it does not specify whether this is a one-time dose or if it is to be given daily, which makes it unclear.
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