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.   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.

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Correct Answer is D

Explanation

A. While furosemide helps reduce fluid overload, it does not directly decrease inflammation.
B. Furosemide does not specifically address pain; its primary purpose is to reduce fluid overload.
C. Furosemide should reduce blood pressure if fluid volume excess was contributing to the elevated blood pressure. If blood pressure increases, this would not be considered an effective response to the medication.
D. Weight loss is a common indicator of the effectiveness of diuretics like furosemide, as it helps to reduce the excess fluid volume in the body.

A. Don sterile gloves. B. Turn on the suction and set the pressure. C. Insert the catheter during the client's inspiration. D. Apply suction while rotating the catheter. E. Rinse the catheter to remove secretions.

Correct Answer is A,B,C,D,E

Explanation

A. The nurse should begin by donning sterile gloves to maintain a sterile field.
B. The suction machine should be turned on, and the pressure should be set before starting the suctioning.
C. The catheter should be inserted during the client’s inspiration to minimize discomfort and maximize
effectiveness.
D. Suction should be applied while rotating the catheter to prevent tissue damage and to clear secretions effectively.
E. After suctioning, the catheter should be rinsed to remove any remaining secretions.

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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

Naxlex Comprehensive Predictor Exams

A nurse is administering furosemide IV bolus to a client who has fluid volume excess. The nurse should recognize which of the following findings as an indication that the medication has been effective?

Correct Answer is D

Explanation

A nurse is caring for a client who requires nasotracheal suctioning. Identify the sequence the nurse should follow to perform suctioning. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is A,B,C,D,E

Explanation

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