A nurse is assisting in the care of a group of children on a pediatric medical surgical unit. Which of the following children should the nurse collect data from first?

A toddler who has periorbital cellulitis and has an axillary temperature of 37.6° C (99.7° F)

An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10

An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding

A child who had a cast placed 4 hr ago and reports numb in the affected extremity

Answer and Explanation

The Correct Answer is D

A. A toddler who has periorbital cellulitis and has an axillary temperature of 37.6°C (99.7°F): A mild temperature in the context of periorbital cellulitis is expected and not an immediate emergency. Although periorbital cellulitis can be serious, this temperature alone does not demand immediate action over other critical symptoms.

B. An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10: A headache with influenza is common and requires monitoring, but unless there are signs of severe neurological involvement, it is not the highest priority compared to potential circulatory compromise.

C. An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding: Mild vomiting or spitting up is common following a pyloromyotomy and is not unusual within the first 24 hours postoperatively. It generally does not require immediate intervention unless persistent or worsening.

D. A child who had a cast placed 4 hr ago and reports numbness in the affected extremity: Numbness may indicate impaired circulation or nerve compression, a sign of possible compartment syndrome. This is a surgical emergency that can result in permanent damage if not promptly assessed and treated.

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 C

Explanation

A. "If I have a health care proxy, then I do not need to have a living will.": A health care proxy and a living will serve different purposes. A living will outlines specific treatment preferences, while a health care proxy designates someone to make decisions. Having one does not eliminate the benefit or need for the other.

B. "My health care proxy designee is not able to sign a consent form on my behalf.": The designee named in a health care proxy is specifically authorized to make healthcare decisions, including signing consent forms, if the client becomes unable to do so themselves.

C. "I do not need to name a relative as my designee in my health care proxy.": A client can choose any competent adult they trust to act as their healthcare proxy; it does not have to be a relative. This flexibility allows clients to select someone they believe will best honor their wishes.

D. "Once my health care proxy is in place, I relinquish my right to make my own decisions.": Having a health care proxy does not remove the client's decision-making rights. The proxy only takes effect if the client becomes unable to make or communicate their own healthcare decisions.

A. “I will use animal skin condoms when having sex” B. “I will put soiled dressings in a tied plastic bag before placing them in the trash" C. “I will place used sharp items in an empty cereal box for disposal” D. “I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water.”

Correct Answer is B

Explanation

A. "I will use animal skin condoms when having sex.": Animal skin condoms do not provide reliable protection against HIV transmission because they have small pores that can allow viruses to pass through. Latex or synthetic condoms are recommended for effective protection.

B. "I will put soiled dressings in a tied plastic bag before placing them in the trash.": Properly disposing of soiled dressings in a securely tied plastic bag helps prevent the spread of infectious material and minimizes the risk of exposure to others, reflecting good infection control practices at home.

C. "I will place used sharp items in an empty cereal box for disposal.": Sharps should be disposed of in a puncture-resistant, labeled sharps container. An empty cereal box is not puncture-proof and can easily be breached, posing a significant risk for needlestick injuries.

D. "I will disinfect contaminated hard surfaces with a mixture of one part peroxide to 10 parts water.": The correct disinfection solution for HIV is a mixture of one part bleach to 10 parts water, not peroxide. Using an incorrect disinfectant reduces the effectiveness of killing the virus on surfaces.

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 assisting in the care of a group of children on a pediatric medical surgical unit. Which of the following children should the nurse collect data from first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about advance directives and a health care proxy. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is reinforcing teaching about home infection prevention with a client who is HIV positive. Which of the following statements by the client indicates an understanding of the teaching

Correct Answer is B

Explanation

A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply)

A nurse is assisting in the care of clients on a postpartum unit. Which of the following events should the nurse identify as needing to initiate a security alert for?

A nurse is assisting with the care of a client. A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

The nurse has reviewed the Nurses' Notes and Vital Signs at 0900. Complete the following sentence by using the lists of options. The client is most at risk for ________ due to ________.

A nurse is caring for a 2-year-old male client. The parent states, "He has started playing with dolls since our baby was born. Does this indicate he will identify as a female as he grows up?" Which of the following responses should the nurse make?

A nurse is assisting with the care of a client in a provider's clinic. For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.

A nurse is caring for a client who has dependent personality disorder. Which of the following manifestations should the nurse expect?

A nurse is assisting with planning care for a client who has a new diagnosis of multiple sclerosis. Which of the interventions should the nurse recommend?