A nurse is caring for a group of clients.
Which of the following findings should the nurse report to the provider?
swer and explanation
An 18-month-old toddler who has a heart rate of 68/min
An adolescent who has a BP of 132/82 mm hg
A 3-month-old infant who has a respiratory rate of 36/min
The Correct Answer is B
Choice A rationale
A rectal body temperature of 37.3 C (99.1 F) in a school-age child is within the normal range, so it does not need to be reported.
Choice B rationale
A heart rate of 68/min in an 18-month-old toddler is below the normal range (80-130 beats per minute). This could indicate a serious condition such as heart block or hypothermia and should be reported to the provider.
Choice C rationale
A blood pressure of 132/82 mm Hg in an adolescent is slightly elevated but within acceptable limits for a teenager, especially if the teenager was nervous or anxious during the measurement.
Choice D rationale
A respiratory rate of 36/min in a 3-month-old infant is within the normal range (30-60 breaths per minute), so it does not need to be reported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Providing a high-calorie diet is a recommended action for a child who has received partial-thickness burns to
over 50% of his body. After a burn injury, the body needs extra calories and protein to heal, fight infection, and maintain its functions. A high-calorie diet can help meet these increased nutritional needs.
Choice B rationale
Administering analgesics intramuscularly (IM) is not a recommended action for a child with partial- thickness burns. Pain management is crucial in burn care, but analgesics should be given orally or intravenously, not IM, to avoid additional pain and tissue damage.
Choice C rationale
Monitoring intake and output is a recommended action for a child who has received partial-thickness burns to over 50% of his body. This can help assess the child’s hydration status, kidney function, and response to fluid replacement therapy.
Choice D rationale
Removing splints during sleep is not a recommended action for a child with partial-thickness burns. Splints are used to prevent contractures by keeping the joints in a functional position. They should be worn as prescribed by the healthcare provider, which often includes during sleep.
Choice E rationale
Changing dressings using aseptic technique is a recommended action for a child who has received partial- thickness burns to over 50% of his body. This can help prevent infection, promote healing, and assess the burn’s progress.
Correct Answer is D
Explanation
Choice A rationale
Performing the examination once every other month is not the recommended frequency. It is generally recommended that males perform a testicular self-examination monthly.
Choice B rationale
Notifying your provider if your testes are firm and egg-shaped may not be necessary, as this is generally considered a normal characteristic of testes. However, any changes in size, shape, or consistency should be reported.
Choice C rationale
Waiting a month after feeling a hard lump is not recommended. If a hard lump is detected during a self-
examination, it should be reported to a healthcare provider immediately, as it could be a sign of testicular cancer.
Choice D rationale
Performing the examination following a warm shower is recommended. The warmth relaxes the scrotum, making it easier to examine the testicles.
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