A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)Exhibit 1

Exhibit 2

Exhibit 3 Graphic Record
Blood pressure 68/46 mm Hg Heart rate 182/min Respiratory rate 32/min
Temperature 38.8°C (101.9°F) SaO2 95% on room air

Skin turgor

Potassium level

Capillary refill

Heart rate

Answer and Explanation

The Correct Answer is D

Rationale:

A. Skin turgor assessment is important in assessing dehydration, but the priority is addressing the tachycardia first.

B. Potassium level is important in managing electrolyte imbalance in gastroenteritis, but the priority is addressing the elevated heart rate first.

C. Capillary refill is an important assessment for circulation, but the priority is addressing the elevated heart rate first.

D. The elevated heart rate (tachycardia) indicates increased workload on the heart, likely due to dehydration or other complications of gastroenteritis. This requires immediate attention to stabilize the infant's condition.

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Correct Answer is {"xRanges":[106.765625,146.765625],"yRanges":[220.609375,260.609375]}

Explanation

A. This region of the chest is expected to be resonant on percussion because of the air in the lung.
B. The right upper quadrant of the abdomen is usually dull on percussion because of the underlying liver.
C. This site is tympanic because of the gas in the intestines.

A. Heliox via inhalation B. Albuterol via nebulizer C. Prednisone by mouth D. 0.9% sodium chloride via IV bolus

Correct Answer is B

Explanation

Rationale:

A) Heliox may be used in the management of severe asthma exacerbations, but albuterol via nebulizer is typically administered first for rapid bronchodilation.

B) Albuterol is a short-acting beta agonist bronchodilator used as the first-line treatment in acute asthma exacerbations to relieve bronchospasm and improve airflow.

C) Prednisone, an oral corticosteroid, may be indicated in the treatment of status asthmaticus, but it is not the first medication administered.

D) 0.9% sodium chloride via IV bolus is not indicated as the initial treatment for status asthmaticus.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to percuss an adolescent's chest and abdomen. Which of the following areas should the nurse expect to hear a dull sound? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Correct Answer is {"xRanges":[106.765625,146.765625],"yRanges":[220.609375,260.609375]}

Explanation

A nurse is assisting with the care of a child who is in status asthmaticus. Which of the following medications should the nurse administer first?

Correct Answer is B

Explanation

A nurse is making a home visit to a 5-year-old child who has cerebral palsy and uses a wheelchair. Which of the following observations made by the nurse indicates that the family needs support and resources to cope with the child's condition?

A nurse is contributing to the plan of care for a preschooler who has moderate partial- thickness burns on both lower extremities. Which of the following interventions should the nurse recommend?

A nurse is assisting with the care of an infant who is postoperative following surgical repair of a cleft lip and palate. Which of the following action should the nurse plan to take?

A nurse is reinforcing teaching with the parent of a child who has a bacterial upper respiratory infection. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is reinforcing teaching with the parent of a school-age child who is undergoing testing for acute lymphoid leukemia (ALL). The nurse should inform the parent that the child will undergo which of the following tests to confirm the diagnosis?

A nurse is assisting with the care of an infant who requires emergency surgery and whose parent is an emancipated adolescent. Which of the following people can sign the informed consent form for the procedure?

A nurse is caring for a toddler who has a respiratory illness and a temperature of 39.3° C (102.7" F). Which of the following actions should the nurse take to reduce the toddler's temperature?

A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has colic.Which of the following instructions should the nurse include in the teaching?