Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a toddler admitted to the hospital.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Body Systems

Findings

Respiratory

Respiratory rate 26/min

Cardiovascular

Heart rate 112/min

Capillary refill 4 seconds

Gastrointestinal

Hyperactive bowel sounds

Integumentary

Diaper area reddened with erythema noted

Extremities cool

Reports no tears

Neurologic

Lethargic

Capillary refill 4 seconds

Hyperactive bowel sounds

Diaper area reddened with erythema noted

Extremities cool

Reports no tears

Lethargic

Respiratory rate 26/min

Heart rate 112/min

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.

Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.

Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.

Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.

Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.

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 A

Explanation

A. Speak in a normal voice at a natural pace: This allows the interpreter to accurately convey the nurse's message without confusion or misinterpretation. Speaking slowly or loudly is unnecessary and can be perceived as disrespectful.

B. Pause in the middle of sentences: Pausing mid-sentence may result in incomplete or confusing information being relayed to the client.

C. Direct statements to the interpreter: The nurse should direct communication to the client to maintain engagement and respect.

D. Use gestures when speaking with the client: Gestures can be misinterpreted, and relying on them reduces clear verbal communication.

A. Sinus tachycardia B. Atrial fibrillation C. Second-degree heart block D. Ventricular asystole

Correct Answer is B

Explanation

A. Sinus tachycardia: Incorrect. Sinus tachycardia shows a regular rhythm with identifiable P waves, not a wavy baseline.

B. Atrial fibrillation: The wavy baseline and absent P waves are characteristic of atrial fibrillation, a common arrhythmia that results from rapid and irregular electrical activity in the atria.

C. Second-degree heart block: Incorrect. Second-degree heart block would show P waves with intermittent conduction of the QRS complex, not a wavy baseline.

D. Ventricular asystole: Incorrect. Ventricular asystole would show no electrical activity, which is different from a wavy baseline.

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

Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who speaks a different language than the nurse and is using an interpreter. Which of the following actions should the nurse take when working with the interpreter?

Correct Answer is A

Explanation

A nurse is caring for a client who is alert and oriented and is receiving continuous ECG monitoring. The cardiac rhythm strip shows a wavy baseline, no distinguishable P waves, and an increased heart rate. The nurse should identify the cardiac rhythm as which of the following?

Correct Answer is B

Explanation

A nurse is caring for a 9-year-old child at a clinic. Exhibits Select the 3 priority actions that the nurse should take.

A nurse is caring for a client who has diabetes mellitus and is receiving long-acting daily insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin?

A home nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan monitor?

A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

A nurse is assessing the coping strategies of a client who has recently retired. Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?

A nurse is teaching a client who is pregnant and has genital herpes simplex virus (HSV). Which of the following statements should the nurse include in the teaching?

A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?

A nurse is caring for a client who is 4 days postpartum following a cesarean birth. Exhibits For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.