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) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.
B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.
C) A respiratory rate of 40/min is within the normal range for an infant.
D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.
Correct Answer is B
Explanation
Rationale:
A) The parent of the adolescent parent may not have legal authority over the infant's medical decisions.
B) An emancipated adolescent parent typically has the legal authority to provide consent for their child's medical procedures.
C) The infant's provider cannot provide consent on behalf of the adolescent parent.
D) The adult sibling of the adolescent parent does not have legal authority unless designated as a legal guardian.
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