Nokea
You measure your 5 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 100 beats per minute • Blood pressure: 85/55. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: A
Rationale: For a 5-year-old, normal ranges are approximately: respiratory rate 20-25 breaths/min, pulse 70-115 beats/min, blood pressure ~90-110/55-65 mmHg. The respiratory rate (32) is slightly high, while the pulse and blood pressure are within normal limits.
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The nurse is caring for a client with a history of epilepsy who is prescribed valproic acid (Depakene). Which of the following laboratory tests should the nurse monitor?
- A. Liver function tests.
- B. Renal function tests.
- C. Complete blood count.
- D. Blood glucose levels.
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, requiring regular monitoring of liver function tests.
A nulligravid client calls the clinic and tells the nurse that she forgot to take her oral contraceptive in the morning. Which of the following should the nurse instruct the client to do?
- A. Take the medication immediately.
- B. Restart the medication in the morning.
- C. Use another form of contraception for 2 weeks.
- D. Take two pills tonight before bedtime.
Correct Answer: A
Rationale: Taking the missed pill immediately maintains hormonal levels, minimizing the risk of ovulation. Additional contraception may be needed if more doses are missed.
A client with heart failure is prescribed furosemide (Lasix). Which assessment finding indicates the medication is effective?
- A. Increased blood pressure.
- B. Decreased edema.
- C. Weight gain.
- D. Elevated potassium levels.
Correct Answer: B
Rationale: Furosemide is a diuretic that reduces fluid overload, so decreased edema indicates effective treatment by promoting fluid excretion.
Your pediatric client weighs 48 pounds. How many mg of a medication would you administer to this client with each dose when the doctor has ordered 5 mg/kg/day in two equally divided doses?
- A. 45 mg
- B. 60 mg
- C. 52 mg
- D. 55 mg
Correct Answer: C
Rationale: To calculate: 48 pounds ÷ 2.2 = 21.82 kg. Then, 5 mg/kg × 21.82 kg = 109.1 mg/day. Divided into two doses: 109.1 ÷ 2 = 54.55 mg, rounded to 52 mg per dose.
A client with a history of myocardial infarction is prescribed aspirin. The nurse should explain that the primary purpose of this medication is to:
- A. Reduce chest pain.
- B. Prevent platelet aggregation.
- C. Lower blood pressure.
- D. Decrease heart rate.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of further clot formation in clients with a history of myocardial infarction.