A nurse is assessing a 2-year-old male toddler in a pediatric clinic during a well-child checkup.

Exhibits

After reviewing the toddler’s current medical record, which of the following interventions should the nurse expect the provider to prescribe?

Protective environment

Blood transfusion

Iron supplementation

Antibiotic continuation

Answer and Explanation

The Correct Answer is C

Choice A rationale: A protective environment is typically indicated for immunocompromised clients, such as those with neutropenia or undergoing chemotherapy, not for uncomplicated anemia. The toddler’s white blood cell count is within the normal range of 5,000 to 10,000/mm³, and no evidence of infection risk or severe immunodeficiency is present. Pallor and low hemoglobin are consistent with iron deficiency anemia, which does not require isolation precautions unless additional hematologic compromise is identified.

Choice B rationale: Blood transfusions are reserved for cases of severe anemia with hemodynamic instability, cardiac compromise, or hemoglobin levels below 7 g/dL. This toddler’s hemoglobin is 8.1 g/dL, which while low, does not meet transfusion threshold in a stable, asymptomatic pediatric patient. Transfusion carries risks like iron overload and alloimmunization, making it inappropriate for mild to moderate anemia. Instead, correction through dietary modification and iron supplementation is preferred for age-related iron-deficiency anemia.

Choice C rationale: Iron supplementation is the standard therapy for iron deficiency anemia, especially in toddlers consuming excessive cow’s milk, which lacks iron and can cause occult intestinal blood loss. Hemoglobin of 8.1 g/dL is below the normal pediatric range of 9.5 to 14 g/dL, confirming anemia. Iron replenishment stimulates erythropoiesis by enabling hemoglobin synthesis. Supplementation corrects deficiency over time and should be paired with dietary education to limit milk to <24 oz/day and include iron-rich foods.

Choice D rationale: Continuing antibiotics is unnecessary unless there is ongoing infection. The toddler has recently completed antibiotic therapy for otitis media, and current symptoms do not suggest infection recurrence. Vital signs are stable and the white blood cell count is within normal limits (5,000–10,000/mm³), indicating no acute bacterial process. Antibiotic overuse may disrupt gut flora, impair iron absorption, and contribute to resistant bacterial strains, which is contraindicated in this clinical scenario.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale

Diarrhea is a common side effect of clozapine, a second-generation antipsychotic medication. It is usually a mild to moderate symptom and does not typically warrant immediate reporting to the provider unless it is severe, persistent, or accompanied by other concerning symptoms like dehydration. It can often be managed with dietary adjustments or over-the-counter antidiarrheal medications, and it does not usually indicate a serious or life-threatening adverse reaction.

Choice B rationale

A fever in a client taking clozapine is a critical finding that must be immediately reported to the provider. Fever can be an early symptom of agranulocytosis, a severe and potentially fatal adverse effect characterized by a dangerously low white blood cell count. Agranulocytosis makes the client highly susceptible to severe infections. A fever may also indicate the onset of neuroleptic malignant syndrome, another serious and life-threatening condition.

Choice C rationale

Polyuria, which is excessive urination, can be a symptom of various conditions but is not a primary concern or contraindication for clozapine administration. It can be associated with increased fluid intake due to xerostomia (dry mouth), a common side effect of clozapine. It does not typically indicate a severe, life-threatening adverse effect like agranulocytosis or neuroleptic malignant syndrome, and thus does not require immediate reporting.

Choice D rationale

Diaphoresis, or excessive sweating, is a frequent side effect of clozapine. It is often related to the drug's anticholinergic effects and thermoregulatory dysfunction. While it can be uncomfortable for the client and may require management, it is not an immediate sign of a life-threatening condition like agranulocytosis or neuroleptic malignant syndrome. Therefore, it does not typically require an immediate report to the provider. *.

A. During this test, I must not eat or drink anything. B. This test will tell me if my baby has a genetic problem. C. During this test, I will push a button if my baby moves. D. I will get oxytocin during this test.

Correct Answer is C

Explanation

Choice A rationale

A nonstress test (NST) does not require the client to fast. The client can eat and drink normally, and sometimes a sugary beverage is even encouraged to stimulate fetal movement, as the test aims to record fetal heart rate accelerations in response to these movements.

Choice B rationale

The nonstress test is a screening tool used to assess fetal well-being by measuring the fetal heart rate's response to fetal movement. It does not provide information about genetic problems, which are typically identified through genetic testing or prenatal diagnostic procedures such as amniocentesis.

Choice C rationale

A key component of the nonstress test involves the mother noting fetal movements. The client is given a marker, often a button, to press each time she feels the baby move. This action correlates the mother's perception of movement with the fetal heart rate accelerations recorded on the monitor.

Choice D rationale

Oxytocin is not administered during a nonstress test. The purpose of this test is to assess the baby's baseline heart rate and accelerations without external stimulation. Oxytocin is used in a contraction stress test, which is a different procedure to evaluate how the baby handles uterine contractions. *.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a 2-year-old male toddler in a pediatric clinic during a well-child checkup. Exhibits After reviewing the toddler’s current medical record, which of the following interventions should the nurse expect the provider to prescribe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

A nurse is teaching a client who is pregnant about nonstress testing. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is planning care for an older adult client who has dementia and a nutritional deficit. Which of the following actions should the nurse plan to take?

A nurse is preparing to administer medication to a client. Which of the following identifiers should the nurse use to identify the client?

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel?

A nurse is reviewing the ECG tracing strip of a client who is receiving telemetry monitoring. The nurse should locate the S-T segment at which of the following locations on the electrocardiographic waveform.

A nurse is assessing a client who is taking losartan. Which of the following findings should the nurse identify as an adverse effect of this medication?

A nurse is caring for a client who is in the latent phase of labor and reports severe back pain. The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station. Which of the following interventions should the nurse implement?

A nurse is caring for a group of clients and identifying what tasks she can delegate to an assistive personnel (AP). Which of the following tasks should the nurse delegate to an AP?

A charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first?

A nurse is assessing a 2-year-old male toddler in a pediatric clinic during a well-child checkup.

Exhibits

After reviewing the toddler’s current medical record, which of the following interventions should the nurse expect the provider to prescribe?