Nokea
Which of the following findings should the nurse report to the provider?
- A. An 18-month-old toddler who has a heart rate of 68/min
- B. A school-age child who has a rectal body temperature of 37.3° C (99.1° F)
- C. An adolescent who has a BP of 132/82 mm Hg
- D. A 3-month-old infant who has a respiratory rate of 30/min
Correct Answer: A
Rationale: The correct answer is A: An 18-month-old toddler who has a heart rate of 68/min. This finding should be reported to the provider because a heart rate of 68/min in an 18-month-old toddler is below the normal range for that age group, which is typically around 100-130/min. This could indicate bradycardia, which may be a sign of an underlying health issue that requires further evaluation and intervention. Reporting this abnormal finding promptly can help the provider assess the toddler's cardiovascular health and determine appropriate management.
The other choices are within normal ranges for their respective age groups:
B: A school-age child with a rectal temperature of 37.3°C (99.1°F) is within the normal range.
C: An adolescent with a blood pressure of 132/82 mm Hg is within the normal range for that age group.
D: A 3-month-old infant with a respiratory rate of 30/min is within the normal
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Specify 2 parameters the nurse should monitor to assess the client's progress.
- A. Number of steatorrhea stools
- B. Intake and output
- C. Respiratory Status (Monitor respiratory)
- D. Presence of periorbital edema
Correct Answer: B,C
Rationale: The correct parameters for the nurse to monitor to assess the client's progress are intake and output (B) and respiratory status (C). Monitoring intake and output is crucial to assess fluid balance and kidney function. Changes in these values can indicate dehydration or fluid overload. Respiratory status should be monitored to assess oxygenation and ventilation, which are essential for tissue perfusion and overall health.
The incorrect choices are A, D, E, F, and G. A (Number of steatorrhea stools) is not directly related to assessing overall client progress. D (Presence of periorbital edema) may be indicative of fluid retention but is not as direct as intake and output monitoring. Choices E, F, and G are not provided, thus not applicable to the question.
Which of the following actions should the nurse take to encourage acceptance of the medication?
- A. Provide an ice pop after administering the medication.
- B. Give 4 oz of milk with the medication.
- C. Mix the medication with the child's favorite food.
- D. Dilute the medication with 8 oz of water.
Correct Answer: A
Rationale: The correct answer is A. Providing an ice pop after administering the medication can create a positive association with taking the medication. The cold sensation and flavor can help mask any unpleasant taste, making the child more likely to accept the medication. Choice B might not be effective as milk may interfere with the medication's absorption. Choice C could work if the child does not detect the medication in the food. Choice D is not ideal as diluting the medication may reduce its effectiveness.
Which of the following findings should the nurse recognize as being consistent with hyperglycemia?
- A. Sweating
- B. Tremors
- C. Pallor
- D. Thirst
Correct Answer: D
Rationale: The correct answer is D: Thirst. Hyperglycemia results in elevated blood sugar levels, leading to increased osmolality and dehydration, triggering thirst as the body attempts to dilute the blood. Sweating (A), tremors (B), and pallor (C) are not typically associated with hyperglycemia. Sweating is more commonly seen in hypoglycemia, tremors can be a sign of low blood sugar, and pallor is not a direct symptom of high blood sugar levels.
7 year old with UTI intervention?
- A. Monitor salicylic acid?
- B. Monitor Pain s fever
Correct Answer: B
Rationale: The correct answer is B: Monitor Pain and Fever. In a 7-year-old with a UTI, monitoring pain and fever is crucial as these symptoms indicate the severity of the infection and response to treatment. Pain and fever can also help in assessing the effectiveness of antibiotics. Monitoring salicylic acid is not relevant as it is not commonly used in UTI management in children due to the risk of Reye's syndrome. The other choices are not provided, but they would likely be incorrect as they are unrelated to UTI management in a 7-year-old.
Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
- A. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.
- B. Provide a pacifier coated with an oral sucrose solution prior to the injections.
- C. Inject the immunizations into the deltoid muscle.
- D. Use a 20-gauge needle for the injections.
Correct Answer: B
Rationale: The correct answer is B: Provide a pacifier coated with an oral sucrose solution prior to the injections. This is an appropriate action for atraumatic care because it helps to reduce pain and distress during procedures, such as injections, by utilizing non-pharmacological comfort measures. The sucrose solution on the pacifier helps to soothe and distract the child, making the experience less traumatic.
Choice A (Apply EMLA cream immediately before injections) is incorrect because while EMLA cream numbs the skin, it does not address the psychological aspect of pain and distress associated with procedures.
Choice C (Inject the immunizations into the deltoid muscle) is incorrect because the location of injection does not directly relate to atraumatic care.
Choice D (Use a 20-gauge needle for the injections) is incorrect because the size of the needle does not address the psychological comfort of the child during the procedure.