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
Sunken fontanels and dry mucous membranes
Temperature 38°C (100.4°F) and pulse rate 124/min
Decreased appetite and irritability
The Correct Answer is B
A. Incorrect. A pale appearance and fluid deficit of 30 mL over 24 hours might require intervention but is not as critical as sunken fontanels and dry mucous membranes.
B. Correct. Sunken fontanels and dry mucous membranes are signs of dehydration, a potential complication of gastroenteritis. These findings should be reported to the provider for further evaluation and intervention.
C. Incorrect. A slightly elevated temperature and an increased pulse rate are common responses to infection and fever in infants.
D. Incorrect. Decreased appetite and irritability can be expected in infants with gastroenteritis and are not as concerning as signs of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
A capillary glucose level of 198 mg/dL in a client receiving total parenteral nutrition (TPN) suggests hyperglycemia, which is a common complication of TPN. TPN solutions are high in glucose, and clients receiving TPN are at risk of developing hyperglycemia. Regular monitoring of blood glucose levels is necessary to detect and manage hyperglycemia promptly.
Choice B rationale:
Serum albumin level of 3.9 g/dL is within the normal range (3.5-5.5 g/dL) and does not indicate a complication of TPN. Low serum albumin levels could suggest malnutrition or liver disease, but in this case, the level is normal.
Choice C rationale:
Hemoglobin (Hgb) level of 15.6 g/dL is within the normal range for both men and women, indicating an adequate oxygen-carrying capacity of the blood. This result does not suggest a complication related to TPN.
Choice D rationale:
White blood cell (WBC) count of 7,000/mm³ is within the normal range (4,500-11,000/mm³) and does not indicate a complication of TPN. Elevated WBC count could suggest an infection, but in this case, the count is normal.
Correct Answer is C
Explanation
A. This is a stimulant laxative that works by increasing the movement of the intestines, helping the stool to come out. However, given the client's third-degree perineal laceration, a rectal suppository might cause discomfort and potentially disrupt the healing process.
B. Incorrect. Loperamide is an antidiarrheal medication and is not appropriate for constipation relief.
C. This is an osmotic laxative that works by drawing water into the intestines, which helps to soften the stool and stimulate bowel movements. It is taken orally and would not interfere with the healing of the perineal laceration.
D. Incorrect. Famotidine is an H2 blocker used to reduce stomach acid and is not indicated for constipation relief.
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