A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

Pale and a 24-hr fluid deficit of 30 mL

Decreased appetite and irritability

Temperature 38° C (100.4° F) and pulse rate 124/min

Sunken fontanels and dry mucous membranes

Answer and Explanation

The Correct Answer is D

A. Incorrect – A 24-hour fluid deficit of 30 mL is mild and does not require immediate intervention.
B. Incorrect – Decreased appetite and irritability are common with gastroenteritis but not as concerning as dehydration.
C. Incorrect – A temperature of 38°C (100.4°F) and pulse of 124/min are mild and expected with infection.
D. Correct – Sunken fontanels and dry mucous membranes are signs of dehydration, which is a major concern in gastroenteritis. Severe dehydration can lead to hypovolemic shock.

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Correct Answer is A

Explanation

A. APs can remind clients to use the incentive spirometer as part of their role in promoting basic care and client independence.
B. Observing the position of the suspended weight is a nursing responsibility because improper traction can lead to complications.
C. Asking the client to describe their pain requires assessment, which is outside the scope of an AP’s role.
D. Checking the pedal pulse is an assessment task that requires nursing judgment and should not be delegated to an AP.

A. Eat a light snack before bedtime. B. Take a 1-hr nap during the day. C. Perform exercises prior to bedtime. D. Stay in bed at least 1 hr if unable to fall asleep.

Correct Answer is A

Explanation

A. Correct – A light snack (such as crackers and milk) can prevent hunger-related wakefulness and promote relaxation.
B. Incorrect – Long naps (>30 minutes) can disrupt nighttime sleep. If necessary, short naps should be limited to 20–30 minutes.
C. Incorrect – Exercise before bed can stimulate the nervous system, making it harder to fall asleep.
D. Incorrect – If unable to sleep after 20–30 minutes, the client should get out of bed and engage in a quiet activity (e.g., reading) to avoid associating the bed with wakefulness.

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A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?

Nursing Test Bank

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