A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

Bulging anterior fontanel

Decreased temperature

Hypertension

Oliguria

Answer and Explanation

The Correct Answer is D

A. Bulging anterior fontanel. A bulging fontanel is associated with increased intracranial pressure, not dehydration. Dehydration is more likely to cause a sunken fontanel.
B. Decreased temperature. Dehydrated infants typically exhibit normal or elevated temperatures, especially if they have an underlying infection or fever. A decreased temperature is not a common sign of dehydration.
C. Hypertension. Dehydration more commonly leads to hypotension or normal blood pressure, depending on severity. Hypertension is not an expected finding in an infant with fluid volume loss.
D. Oliguria. Decreased urine output (oliguria) is a classic and expected sign of dehydration in infants. It indicates the kidneys are conserving fluid due to inadequate intake and fluid loss from vomiting and diarrhea.

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Correct Answer is A

Explanation

A. Measure the tubing from the nose to the distal port. Proper placement of an NG tube requires measuring from the tip of the nose to the earlobe, then to the xiphoid process. This ensures the tube reaches the stomach without curling or entering the airway.
B. Position the child at a 10 to 20 angle after feeding. A head elevation of at least 30 to 45 degrees is necessary during and after NG feedings to reduce the risk of aspiration. A 10 to 20 degree angle is too low and unsafe for post-feeding positioning.
C. Complete the feeding in 5 min. NG feedings should be given slowly over 20 to 30 minutes to prevent gastrointestinal discomfort, cramping, or vomiting. A 5-minute infusion is too rapid and may overwhelm the child’s digestive capacity.
D. Warm the formula in the microwave. Microwaving formula can lead to uneven heating and hot spots, which pose a burn risk to the child. Formula should be warmed by placing the container in warm water and testing the temperature before administration.

A. Providing a needle exchange program for community members. B. Providing education to fifth graders about the risks of substance use. C. Providing a list of outpatient substance use support services to give to clients who are discharged from inpatient treatment. D. Providing education to pregnant clients in a sober living community about the fetal risks of substance use during pregnancy

Correct Answer is B

Explanation

A. "You should not delegate this task because you have the capability to obtain clients' weights." The ability to perform a task does not mean it cannot be delegated. Delegation helps manage workload effectively as long as the task is appropriate for the role.
B. "You can delegate this task if the AP has been trained to use our scales." Weighing clients is a routine, noninvasive task that can be delegated to assistive personnel, provided they are trained and competent in using the equipment properly.
C. "You can delegate this task to an AP for new clients before performing a nursing assessment." Initial assessments require nursing judgment and should not be delegated. Data collection like weight should occur after the nurse completes the first assessment.
D. "You should not delegate this task because it requires nursing judgment." Weighing a client does not require clinical judgment and is considered appropriate for delegation to trained assistive personnel under supervision.

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A nurse in an urgent care clinic is caring for an infant who presents with vomiting, diarrhea, and decreased oral intake. Which of the following manifestations should the nurse expect?

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