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?"

Answer and Explanation

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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Correct Answer is B

Explanation

A. Apex of the heart: While the apex of the heart is a common site to listen to the heart sounds, it’s not typically used to measure the heart rate in infants.
B. Brachial artery: This is the correct answer. The brachial artery, located on the inside of the upper arm, is commonly used to assess the heart rate in infants.
C. Carotid artery: The carotid artery, located on the neck, is commonly used to assess the heart rate in adults, but it’s not typically used in infants.
D. Radial artery: The radial artery, located on the wrist, is also commonly used to assess the heart rate in adults, but it’s not typically used in infants.

A. Stop the enema and document that the client did not tolerate the procedure. B. Allow the client to expel some fluid before continuing. C. Encourage the client to bear down. D. Lower the height of the solution container.

Correct Answer is D

Explanation

A. Stop the enema and document that the client did not tolerate the procedure: This action might be necessary in some cases, but it’s not the first action to take. The nurse should first try to alleviate the client’s discomfort.

B. Allow the client to expel some fluid before continuing: This action could potentially relieve some discomfort, but it’s not the most effective initial response. The cramping is likely due to the speed at which the fluid is entering, not the amount of fluid already administered.

C. Encourage the client to bear down: This action is not typically recommended during an enema administration as it could increase discomfort.

D. Lower the height of the solution container: This is the correct action. Lowering the height of the solution container will decrease the speed at which the fluid is entering the client’s rectum, which can help alleviate cramping and discomfort. Therefore, option D is the most appropriate action for the nurse to take.

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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?

Nursing Test Bank

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