Nokea
The nurse is reviewing the assessment findings of a 5-year-old child. The nurse recognizes which vital sign is not within normal limits?
- A. Pulse 73
- B. Blood pressure 90/60 mmHg
- C. Respiratory rate 24
- D. Temperature 98.6°F (37°C)
Correct Answer: C
Rationale: A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits.
You may also like to solve these questions
The nurse recognizes which of the following is considered an external disaster?
- A. Computer system failure
- B. A walkout and strike by nursing staff
- C. Mass shooting at a nearby park
- D. Chemical leak in the critical care units
Correct Answer: C
Rationale: A mass shooting at a nearby park is an external disaster, as it occurs outside the facility and impacts hospital operations. The others are internal disasters.
The nurse in the medical-surgical unit is preparing the room for a client being admitted with varicella-zoster (chickenpox). Which of the following infection control precautions should the nurse implement?
- A. Place a surgical mask on the client during transport out of the client's room
- B. Remove all alcohol-based hand rubs from the room
- C. Wear a face shield while providing care
- D. Asking the client to put on a clean mask each time someone enters the room
Correct Answer: A
Rationale: Varicella requires airborne and contact precautions, including a mask on the client during transport.
The nurse prepares to insert a peripheral vascular access device (PVAD) in the client's cephalic vein. The nurse plans to align the catheter how many degrees above the targeted vein?
- A. 10-30 degrees
- B. 30-45 degrees
- C. 45-90 degrees
- D. 45-60 degrees
Correct Answer: A
Rationale: A 10-30 degree angle is optimal for PVAD insertion to enter the vein without piercing through it. Higher angles increase the risk of vein perforation or improper placement.
The nurse is caring for a client with a Sengstaken-Blakemore tube. The nurse performs safety checks at the beginning of the shift and ensures which priority item is readily available at the bedside?
- A. Trach kit
- B. Scissors
- C. Obturator
- D. Yankauer suctioning
Correct Answer: B
Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding and has balloons that can cause airway obstruction if inflated improperly. Scissors must be at the bedside to cut the tube in an emergency. Trach kits, obturators, and Yankauer suction are not relevant.
The nurse is recommending respite care to a client and their caregiver. The nurse understands that this care is designed to
- A. Improve the quality of life of clients and families who are experiencing problems related to life-threatening illnesses.
- B. Provide a variety of health and social services to specific patient populations.
- C. Have clients live with comfort, independence, and dignity while easing the pain of terminal illness.
- D. Offers short-term relief by providing caregivers who support the ill, disabled, or frail older adults time to relax.
Correct Answer: D
Rationale: Respite care provides temporary relief for caregivers, allowing them rest. Other options describe palliative or comprehensive care services.