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 A
Explanation
A. This statement is appropriate because it respects the client’s autonomy and acknowledges that the client has the right to withdraw consent at any time.
B. Telling the client their doctor wouldn't have ordered the treatment unless it was necessary can be dismissive of the client’s concerns and feelings.
C. While it’s important to acknowledge that nervousness or anxiety is a normal response, this statement does not directly address the client’s concern about not proceeding with the treatment.
D. Telling the client that most people feel better after the procedure may sound dismissive of the
client’s hesitation and doesn’t address their concerns directly.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
Explanation
The nurse should first anticipate the need to Obtain IV access then Prepare to administer IV fluids.
Rationale
First Anticipated Step: Obtain IV Access:
In a client with hypotension and anemia, immediate IV access is crucial to administer fluids or blood
products to stabilize the client’s condition before the endoscopy. Given the client’s low blood pressure and heart rate, they may need IV fluids (such as saline or Ringer's lactate) to help improve circulation and maintain perfusion. This is essential before proceeding with further interventions like the planned endoscopy.
Second Anticipated Step:
Prepare to administer IV fluids:
The client's low blood pressure and the potential for significant blood loss suggest that IV fluids will be necessary to restore blood volume and improve hemodynamic stability before endoscopy. Normal saline or Lactated Ringer's are commonly used for volume resuscitation in this scenario.
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