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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The incentive spirometer should be used more frequently (every 1-2 hours) to promote lung expansion and reduce the risk of pneumonia.
B. Bed rest should be minimized to promote circulation and reduce the risk of deep vein thrombosis (DVT).
C. Range-of-motion exercises improve circulation, prevent joint stiffness, and promote overall mobility.
D. Placing a pillow under the knees can interfere with circulation and promote flexion contractures.
Correct Answer is C
Explanation
A. Canned black beans often contain high levels of sodium, which can contribute to hypertension.
B. Red meat, especially fatty cuts, can raise blood pressure and should be limited in a hypertensive diet.
C. Fish, particularly fatty fish like salmon, is beneficial for individuals with hypertension because it provides omega-3 fatty acids, which can lower blood pressure.
D. Cheese is typically high in sodium and saturated fats, which can exacerbate hypertension.
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