A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?
"I am going to listen to your heart."
"Can I listen to your lungs?"
"I am going to take your blood pressure now."
"Can you stand very still while I feel how warm you are?"
The Correct Answer is A
A. “I am going to listen to your heart.”: This is the correct answer. It is a clear, simple statement that informs the child about what is going to happen. It is important to use language that is appropriate for the child’s age and development.
B. “Can I listen to your lungs?”: While this is a polite way to ask for consent, it might confuse a toddler who may not understand what “lungs” are.
C. “I am going to take your blood pressure now.”: This statement might be too complex for a toddler to understand. It’s better to use simpler language.
D. “Can you stand very still while I feel how warm you are?”: This statement might be confusing for a toddler. It’s better to use clear and direct language.
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Related Questions
Correct Answer is B
Explanation
A. Percuss each lung segment for 15 min: While percussion is a part of chest physiotherapy, it doesn’t typically need to be performed for 15 minutes per lung segment. The duration can vary based on the child’s needs and tolerance.
B. Administer albuterol prior to CPT: This is the correct answer. Albuterol is a bronchodilator that can help open the airways and make the chest physiotherapy more effective.
C. Perform CPT immediately after the child eats: This is not recommended because it can increase the risk of vomiting. It’s usually better to perform CPT before meals or at least 1 hour after meals.
D. Perform vibration during the client’s inspirations: Vibration is typically performed during exhalation, not inspiration, to help loosen and mobilize secretions in the lungs.
Correct Answer is D
Explanation
A. Notify the provider: This might not be necessary at this point unless the child shows other signs of dehydration or illness.
B. Perform a bladder scan at the bedside: This is typically done if there’s a concern about urinary retention, which doesn’t seem to be the case here.
C. Provide oral rehydration fluids: This might be considered if the child shows signs of dehydration, but based on the information given, it’s not clear that this is necessary.
D. Continue to monitor the client: This is the best action based on the information provided. The nurse should continue to monitor the child’s urine output, as well as other signs of hydration and overall health. If the urine output decreases further or the child shows other concerning symptoms, then the nurse might need to take further action.
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