Nokea
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.
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A nurse is caring for a toddler who has a respiratory illness and a temperature of 39.3° C (102.7° F). Which of the following actions should the nurse take to reduce the toddler's temperature?
- A. Give the toddler a tepid bath.
- B. Administer an aspirin suppository.
- C. Remove the toddler's extra clothing.
- D. Apply a cooling blanket.
Correct Answer: C
Rationale: Removing extra clothing allows heat loss safely. Tepid baths risk shivering, aspirin risks Reye's syndrome, and cooling blankets are for severe cases.
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 assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority?
- A. Skin turgor
- B. Potassium level
- C. Capillary refill
- D. Heart rate
Correct Answer: D
Rationale: The elevated heart rate (tachycardia) at 182/min indicates increased cardiac workload, likely due to dehydration from gastroenteritis, requiring immediate attention. While skin turgor, potassium levels, and capillary refill are important, tachycardia is the priority to stabilize the infant.
A nurse is caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority?
- A. Monitor capillary refill of the casted extremity.
- B. Use the palms of the hands when supporting the cast.
- C. Examine the skin at the cast edges.
- D. Instruct the child not to put anything inside the cast.
Correct Answer: A
Rationale: Monitoring capillary refill is critical to assess circulation and detect complications like compartment syndrome post-cast application. Supporting the cast, checking skin, and instructing the child are important but secondary to ensuring circulation.
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.