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: While noting the frequency of drooling is important, it is not the most critical assessment.
Choice B reason: Observing the appearance of oral mucosa is less critical than assessing the ability to swallow.
Choice C reason: Assessing speech patterns is important but secondary to swallowing ability in terms of immediate safety.
Choice D reason: This is the correct choice. The ability to chew and swallow is crucial for preventing aspiration and maintaining nutrition.
Correct Answer is D
Explanation
Choice A reason: Limiting water intake is not recommended as adequate hydration is important, especially when sick.
Choice B reason: Checking blood glucose every 8-12 hours is not frequent enough; it should be monitored more often during illness.
Choice C reason: Drinking juice every hour is not necessary and could lead to hyperglycemia if not balanced with insulin.
Choice D reason: This is the correct choice. It is crucial to continue administering insulin as prescribed to manage blood glucose levels, even if the child is not eating as much.
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