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

Answer and Explanation

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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Correct Answer is A

Explanation

A. A licensed practical nurse (LPN) is capable of performing sterile dressing changes, which is within their scope of practice.
B. An admission assessment requires a registered nurse (RN) to evaluate and formulate a comprehensive care plan, which exceeds the scope of an LPN.
C. Discharge teaching requires the RN’s expertise to provide in-depth education and ensure the patient understands the plan.
D. Completing the Glasgow Coma Scale requires an RN to assess neurological status and make appropriate decisions about care.

A. Hypotension B. Hematuria C. Weight loss D. Polyuria

Correct Answer is B

Explanation

A. Hypotension is not typically associated with acute glomerulonephritis. Instead, hypertension is more commonly seen due to fluid retention and increased vascular resistance.
B. Hematuria is a hallmark finding of acute glomerulonephritis. This condition often leads to blood in the urine, which can be seen as reddish or smoky-colored urine.
C. Weight loss is not typically associated with acute glomerulonephritis. Weight gain is more common due to fluid retention and edema caused by impaired kidney function.
D. Polyuria (excessive urination) is generally not expected in acute glomerulonephritis. Instead, oliguria (decreased urine output) is more typical, as kidney function is impaired and fluid retention occurs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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