A 3-year-old admitted to the hospital with croup has the following vital signs: heart rate 90, respiratory rate 48, blood pressure 100/52, and temperature 98.8°F (37.1°C). The parents ask the nurse if these vital signs are normal. The nurse's best response is:
"Your son's respiratory rate is elevated, but the other vital signs are within the normal range."
"Your son's heart rate is elevated, but the other vital signs are within the normal range."
"Your son's blood pressure is elevated, but the other vital signs are within the normal range."
"Your son's temperature is elevated, but the other vital signs are within the normal range."
The Correct Answer is A
Choice A reason: This is the correct choice. A respiratory rate of 48 is high for a 3-year-old, indicating that the croup is affecting his breathing.
Choice B reason: This choice is incorrect. A heart rate of 90 is within the normal range for a 3-year-old.
Choice C reason: This choice is incorrect. A blood pressure of 100/52 is within the normal range for a 3-year-old.
Choice D reason: This choice is incorrect. A temperature of 98.8°F (37.1°C) is within the normal range for a 3-year-old.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Administering a bolus of D10W is not the first-line treatment for severe dehydration and may not address the immediate fluid needs of the infant.
Choice B reason: Offering an oral rehydration solution is not appropriate for an infant with severe dehydration and a compromised ability to hold down fluids.
Choice C reason: Administering a bolus of hypertonic saline is not typically the initial treatment for dehydration and could potentially worsen the infant's condition.
Choice D reason: This is the correct choice. Administering a bolus of normal saline is the immediate action to treat severe dehydration and restore circulatory volume.
Correct Answer is C
Explanation
Choice A reason: Keeping alarm levels low is important to reduce stress and promote a healing environment, but it is not the most impactful intervention for personalized care.
Choice B reason: Dimming the lights at night helps maintain a normal sleep-wake cycle, which is beneficial but not as specific to the client's individual needs as continuity of care.
Choice C reason: Having the same nurses care for the patient on consecutive days can provide consistency and build trust, which is especially important for a child in critical condition.
Choice D reason: While visits from school friends can be uplifting, they may not be feasible or appropriate for a client in critical condition in the PICU. The priority is ensuring stable and consistent care.
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