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 A
Explanation
Rationale:
A) Montelukast is a leukotriene receptor antagonist that helps prevent bronchospasms by reducing inflammation in the airways.
B) Montelukast is not a corticosteroid; it works through a different mechanism to control asthma symptoms.
C) Montelukast is not used for acute asthma attacks; it is used for long-term management and prevention of asthma symptoms.
D) Montelukast can be taken once daily, typically in the evening, and does not necessarily need to be taken first thing in the morning.
Correct Answer is A
Explanation
Rationale:
A) The nurse should use a 5 French urinary catheter for the 13-month-old toddler.
This is because the size of the catheter should be appropriate for the age and weight
of the child, and a smaller catheter will cause less trauma and discomfort to the urethra.
B) A 12 French catheter might be too large and could cause trauma to the urethra in a 13-month-old toddler.
C) A 10 French catheter might be too large and could cause trauma to the urethra in a 13-month-old toddler.
D) A 14 French catheter is larger and may be too invasive for a 13-month-old toddler.
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