A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?

BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F)

BP 79/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38° C (100.4" F)

BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7° C (98.1° F)

BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6" C (99.7" F)

Answer and Explanation

The Correct Answer is B

A. These vital signs are generally within expected ranges for a 2-year-old child.

B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.

C. These vital signs are within normal limits for a 2-year-old child.

D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.

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Correct Answer is ["200"]

Explanation

To calculate the infusion rate in mL/hr for administering 1 g of ceftriaxone sodium in 100 mL of dextrose 5% in water over 30 minutes, you would use the formula: (Total Volume in mL / Time in hours) = Rate in mL/hr. Since the time frame is 30 minutes, you convert this to hours by dividing by 60, which is 0.5 hours. Therefore, the calculation is 100 mL / 0.5 hours = 200 mL/hr. Rounding to the nearest whole number, the nurse should set the pump to deliver 200 mL/hr.

A. Maintain a saline-lock. B. Check the child's daily weight. C. Educate the parents about potential complications. D. Place the child on a no-salt-added diet.

Correct Answer is B

Explanation

A. Maintaining a saline-lock is important but not the highest priority in this context.

B. Checking the child's daily weight is a priority to monitor for fluid retention and changes in fluid status, which are critical in managing acute glomerulonephritis.

C. Educating parents is important but comes after ensuring the child's immediate physical needs are addressed.

D. While a no-salt-added diet may be recommended, monitoring fluid status and weight is more urgent for assessing and managing the condition.

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A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["200"]

Explanation

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

Correct Answer is B

Explanation

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