A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)Exhibit 1
Exhibit 2
Exhibit 3 Graphic Record
Blood pressure 68/46 mm Hg Heart rate 182/min Respiratory rate 32/min
Temperature 38.8°C (101.9°F) SaO2 95% on room air
Skin turgor
Potassium level
Capillary refill
Heart rate
The Correct Answer is D
Rationale:
A. Skin turgor assessment is important in assessing dehydration, but the priority is addressing the tachycardia first.
B. Potassium level is important in managing electrolyte imbalance in gastroenteritis, but the priority is addressing the elevated heart rate first.
C. Capillary refill is an important assessment for circulation, but the priority is addressing the elevated heart rate first.
D. The elevated heart rate (tachycardia) indicates increased workload on the heart, likely due to dehydration or other complications of gastroenteritis. This requires immediate attention to stabilize the infant's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A) Taking rectal temperatures may increase the risk of infection and is not typically recommended during chemotherapy.
B) Live vaccines such as MMR are generally contraindicated during chemotherapy due to the risk of vaccine-related complications in immunocompromised individuals.
C) Going to the park may expose the child to environmental pathogens and is not recommended during chemotherapy.
D) Inspecting the inside of the child's mouth for sores is important for early detection of oral mucositis, a common side effect of chemotherapy that can increase the risk of infection.
Correct Answer is B
Explanation
Rationale:
A) Foods high in fiber are generally healthy and do not need to be avoided with lisinopril.
B) Lisinopril can increase potassium levels in the blood, so clients should avoid high- potassium foods to prevent hyperkalemia.
C) Foods high in vitamin K are typically associated with blood clotting and are not contraindicated with lisinopril.
D) Dairy products are not specifically contraindicated with lisinopril, although they should be consumed in moderation as part of a balanced diet.
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