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
The Correct Answer is D
A. A small fluid deficit of 30 mL is not concerning unless it worsens or additional symptoms develop.
B. Decreased appetite and irritability can be expected with gastroenteritis and may not require immediate intervention.
C. A mild fever and increased pulse rate can be expected, but if these values remain stable and other signs of dehydration or worsening illness are absent, they do not require immediate intervention.
D. Sunken fontanels and dry mucous membranes are signs of dehydration and should be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sitting in a chair next to the bed provides a comfortable and professional setting, allowing the nurse to engage with the client at eye level.
B. Sitting on the bed may be seen as too informal and might invade the client’s personal space.
C. Standing at the side of the bed can create a sense of distance and is less personal.
D. Standing at the foot of the bed may make the nurse seem detached and less approachable.
Correct Answer is A
Explanation
A. Administering a cathartic suppository 30 minutes prior to scheduled defecation times can help stimulate bowel movements in clients with spinal cord injuries, aiding in bowel training.
B. Refined grains can lead to constipation, and increasing fiber intake is typically preferred over refined grains in a bowel training program.
C. A cold drink is not a standard or recommended method to stimulate bowel movements in clients with spinal cord injuries.
D. Fluid intake should generally be higher than 1,500 mL per day, as adequate hydration is important to prevent constipation and support healthy bowel function.
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