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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client who is 1 day postoperative following a vertebroplasty may be stable enough for early discharge, freeing up a bed for incoming disaster victims.
B. A client with a sealed implant for radiation therapy may require monitoring and cannot be safely discharged early due to potential complications.
C. A client with COPD and a respiratory rate of 44/min requires immediate care and cannot be safely discharged.
D. A client receiving heparin for deep vein thrombosis may be stable but requires monitoring, making early discharge unsafe.
Correct Answer is D
Explanation
A. Encouraging the client to spend time in the dayroom may increase stimulation and worsen manic symptoms. A quiet, calm environment is typically more beneficial.
B. Withdrawing privileges is punitive and may escalate agitation or irritability in a client with mania.
C. Seclusion should only be used if the client is a danger to themselves or others. It is not a first-line intervention for anxiety or manic symptoms.
D. Encouraging the client to take frequent rest periods helps manage manic symptoms by preventing fatigue and promoting some level of structure and control over their activities.
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