A nurse is caring for an infant who has gastroenteritis.
Which of the following assessment findings should the nurse report to the provider?
Sunken fontanels and dry mucous membranes
Temperature 38° C (100.4° F) and pulse rate 124/min.
Decreased appetite and irritability.
Pale and a 24-hr fluid deficit of 30 mL.
The Correct Answer is A
These are signs of severe dehydration in an infant, which can be life-threatening and should be reported to the provider immediately. The infant may need intravenous fluids and electrolytes to restore hydration and prevent complications.
Choice B is wrong because a temperature of 38° C (100.4° F) and pulse rate of 124/min are not abnormal for an infant and do not indicate severe dehydration. These are common findings in an infant who has gastroenteritis, which is an inflammation of the stomach and intestines caused by a virus, bacteria, or parasite.
Choice C is wrong because decreased appetite and irritability are also common findings in an infant who has gastroenteritis, but they do not indicate severe dehydration. The nurse should encourage oral rehydration with fluids such as breast milk, formula, or oral electrolyte solution.
Choice D is wrong because pale skin and a 24-hr fluid deficit of 30 mL are not signs of severe dehydration in an infant.
A fluid deficit of 30 mL is less than 1 oz and is not significant for an infant who weighs about 10 kg (22 lbs). A fluid deficit of more than 10% of body weight would indicate severe dehydration.
Normal ranges for vital signs in infants are as follows:
- Temperature: 36.5° C to 37.5° C (97.7° F to 99.5° F)
- Pulse rate: 100 to 160/min
- Respiratory rate: 30 to 60/min
- Blood pressure: 65/41 to 100/50 mm Hg
Normal ranges for fluid intake and output in infants are as follows:
- Fluid intake: 100 to 150 mL/kg/day
- Fluid output: 1 to 2 mL/kg/hr
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. "I can start the medication 30 minutes earlier."Choice A rationale: This is an inappropriate response, as the nurse should not adjust the time and schedule for the administration of alteplase recombinant, which is a time-sensitive medication used to treat a thrombus in the coronary artery. The administration of this medication must be done within a specific time frame to be effective.Choice B rationale: This is the correct answer. Alteplase recombinant is a thrombolytic medication used to dissolve blood clots in the coronary artery. It is a time-sensitive medication, and it is crucial to administer it as soon as possible to minimize the damage to the heart muscle. Starting the medication 30 minutes earlier is an appropriate action to include in the plan of care, as it can help ensure the medication is administered within the recommended time frame.Choice C rationale: This is an inappropriate response. Alteplase recombinant should be administered within a specific time frame, typically within 3 to 4.5 hours of the onset of symptoms. Waiting up to 2 hours after the usual schedule time to give the medication would be outside the recommended time frame and could potentially reduce the effectiveness of the treatment.Choice D rationale: This is an inappropriate response. Alteplase recombinant should be infused at a specific rate, as recommended by the manufacturer or healthcare provider. Infusing the medication at a faster rate could increase the risk of adverse effects and should not be included in the plan of care without specific instructions from the healthcare provider.
Correct Answer is C
Explanation
Having interdisciplinary team meetings for the client on a regular basis.
This action best promotes communication among staff caring for the client because it allows for consistent and coordinated care planning, information sharing, and goal setting for the client who has expressive aphasia and right hemiparesis following a stroke.
Choice A is wrong because posting swallowing precautions at the head of the client’s bed does not promote communication among staff, but rather informs them of the client’s risk of aspiration due to dysphagia, which is a common complication of stroke.
Choice B is wrong because noting changes in the treatment plan in the client’s medical record is a standard practice that does not necessarily enhance communication among staff, but rather documents the client’s progress and interventions.
Choice D is wrong because recording the client’s progress in the nurses’ notes is also a standard practice that does not necessarily enhance communication among staff but rather provides a summary of the client’s status and care.
Expressive aphasia is an acquired language disorder that affects the ability to produce spoken or written language, while right hemiparesis is a weakness or partial paralysis of the right side of the body.
Both of these conditions are caused by damage to the left hemisphere of the brain, which is responsible for language and motor control of the right side of the body. Stroke and traumatic brain injury are common causes of left hemisphere-damage
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