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A nurse is collecting data from a 1-month-old infant who has just undergone a hernia repair. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 37.4° C (99.3° F)
- B. Apical pulse 155/min
- C. Respiratory rate 40/min
- D. Blood pressure 64/40 mm Hg
Correct Answer: D
Rationale: Blood pressure of 64/40 mm Hg is abnormally low, indicating potential shock or dehydration, requiring immediate reporting. Other findings are within normal ranges for a 1-month-old.
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A nurse in a provider's office is collecting data from an adolescent who has juvenile idiopathic arthritis and has been taking ibuprofen daily for the last 6 months. Which of the following client statements should the nurse report to the provider?
- A. I have morning stiffness in my joints.
- B. I have been taking a multivitamin that contains iron.
- C. I noticed some blood in my stool this morning.
- D. I skipped taking my ibuprofen last week after I went swimming.
Correct Answer: C
Rationale: Blood in stool suggests possible GI bleeding from long-term ibuprofen use, requiring urgent reporting. Stiffness is expected, vitamins are benign, and a single missed dose is less critical.
A nurse is contributing to a plan of care for a 24-month-old toddler. Which of the following actions should the nurse take?
- A. Allowing the toddler to button up their own shirt
- B. Asking the toddler questions that have 'yes' or 'no' answers
- C. Providing the toddler with opportunities to share toys with others
- D. Making sure the toddler has at least one nap during the day
Correct Answer: D
Rationale: Ensuring a nap supports rest and development. Buttoning shirts, yes/no questions, and sharing toys are beneficial but not the priority over rest for a toddler's well-being.
A nurse is reviewing the medical record of a school-age child who is current on recommended immunizations. Which of the following immunizations should the nurse plan to administer at the 11-year-old well-child visit?
- A. Tetanus, diphtheria, acellular pertussis (Tdap)
- B. Haemophilus influenzae type b (Hib)
- C. Inactivated poliovirus (IPV)
- D. Rotavirus (RV)
Correct Answer: A
Rationale: Tdap is recommended at 11-12 years as a booster. Hib, IPV, and RV are given in infancy, not at this age.
A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has colic. Which of the following instructions should the nurse include in the teaching?
- A. Offer a pacifier when your baby is fussy.
- B. You should offer water in between feedings.
- C. You should place a warm heating pad on your baby's abdomen.
- D. Allow your baby to cry for 5 minutes before responding.
Correct Answer: A
Rationale: A pacifier soothes colicky infants. Water risks intoxication, heating pads may burn, and delayed response increases distress in young infants.
A nurse is preparing to percuss an adolescent's chest and abdomen. Which of the following areas should the nurse expect to hear a dull sound?
- A. This region of the chest is expected to be resonant on percussion because of the air in the lung.
- B. The right upper quadrant of the abdomen is usually dull on percussion because of the underlying liver.
- C. This site is tympanic because of the gas in the intestines.
Correct Answer: B
Rationale: The right upper quadrant is dull due to the liver. The chest is resonant, and intestines are tympanic.