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 D
Explanation
Choice A rationale
Administering methylprednisolone, a corticosteroid, can help reduce inflammation. However, it is not the first-line treatment for severe anaphylaxis.
Choice B rationale
Administering oxygen can help improve the child’s oxygenation, but it is not the first action the nurse should take in this situation.
Choice C rationale
Administering a nebulized bronchodilator can help relieve wheezing, but it is not the first action the nurse should take in this situation.
Choice D rationale
Administering epinephrine is the first-line treatment for anaphylaxis. It works quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, and reduce swelling of the face, lips, and throat.
Correct Answer is C
Explanation
Choice A rationale
Washing the site with alcohol prior to applying the cream is not recommended. Alcohol can cause skin irritation and dryness, which may increase the discomfort during the procedure.
Choice B rationale
Rubbing the cream into the skin is not advised. The cream should be applied in a thick layer and not spread on the skin. Rubbing the cream can cause it to absorb into the skin too quickly and reduce its numbing effect.
Choice C rationale
Applying the cream 1 hour before the procedure is the correct action. Lidocaine and prilocaine cream should be applied at least 1 hour before the procedure to ensure adequate numbing of the skin.
Choice D rationale
The cream should not be left on the skin during the procedure. The healthcare provider will remove the cream just before the procedure. Leaving the cream on the skin could interfere with the procedure.
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