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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Incorrect. While it's important to maintain social interaction with the client, avoiding excessive conversation during feeding is recommended. Distractions can interfere with the client's ability to focus on swallowing and increase the risk of aspiration.

B. Incorrect.Coughing is a natural reflex that helps to clear the airway of any material that may have been aspirated. Discouraging coughing could potentially lead to a more serious problem.

C. Correct.Sitting at or below the client's eye level provides a clearer view of the food and helps the client maintain control over their swallowing. This can reduce the risk of aspiration.

D. Incorrect.Lifting the chin can actually increase the risk of aspiration by narrowing the opening to the trachea (windpipe). It's generally recommended to avoid lifting the chin during swallowing.

A. Bilateral diffuse wheezing. B. Shortness of breath on exertion. C. Temperature of 100.5 °F (38.1 °C). D. Yellow expectorated sputum.

Correct Answer is B

Explanation

Among the given assessment findings, the one that warrants the most immediate intervention by the nurse is the shortness of breath on exertion. Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.

While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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