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A nurse is caring for an 8-year-old child on an inpatient pediatric unit.

Exhibits
Click to highlight the findings that indicate the client requires immediate follow-up. To deselect a finding, click on the finding again

Body System

Findings

Integumentary

Skin feels cool to the touch.

Capillary refill 3 seconds in left foot

Dressing on left hand shows small amount of moisture through gauze.

Vital Signs

Blood pressure 102/50 mm Hg

Temperature 35.8° C (96.4° F)

Respiratory rate 20/min

Genitourinary

Output of 25 mL dark amber urine through catheter

Skin feels cool to the touch.

Capillary refill 3 seconds in left foot

Dressing on left hand shows small amount of moisture through gauze.

Blood pressure 102/50 mm Hg

Temperature 35.8° C (96.4° F)

Respiratory rate 20/min

Output of 25 mL dark amber urine through catheter

Answer and Explanation

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

Rationale for correct choices:

Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Give an antibiotic 30 min before dialysis: Some antibiotics may require timing adjustments around dialysis, but this depends on the specific drug and provider orders. Administering antibiotics is not universally required before each dialysis session.

B. Check the vascular access site for bleeding after dialysis: Monitoring the vascular access site for bleeding, swelling, or infection is a critical safety measure after hemodialysis. Proper assessment helps prevent complications such as hemorrhage or thrombosis.

C. Rehydrate with dextrose 5% in water for orthostatic hypotension: Fluid administration during or after dialysis must be carefully managed due to the risk of fluid overload. Standard rehydration with dextrose 5% in water is not routinely recommended for hypotension after dialysis.

D. Withhold all medications until after dialysis: Not all medications should be withheld; some are given before or during dialysis depending on their pharmacokinetics and dialysis clearance. Blanket withholding of medications can be unsafe and may lead to untreated conditions.

A. Choose high-fat cheese as a meat substitute. B. Choose foods high in vitamin B12 C. Limit intake of foods high in vitamin C. D. Limit intake of nuts and legumes.

Correct Answer is B

Explanation

Rationale:

A. Choose high-fat cheese as a meat substitute: Cheese is an animal-derived product and not part of a vegan diet. Additionally, it is high in saturated fat, which can contribute to cardiovascular risk.

B. Choose foods high in vitamin B12: Vitamin B12 is primarily found in animal products, so vegans are at risk for deficiency. Including fortified foods or supplements helps prevent anemia and neurological complications.

C. Limit intake of foods high in vitamin C: Vitamin C-rich foods are beneficial for overall health and can improve non-heme iron absorption from plant sources. There is no reason to limit these foods in a vegan diet.

D. Limit intake of nuts and legumes: Nuts and legumes are excellent plant-based sources of protein, healthy fats, and micronutrients. Restricting them would reduce the nutritional adequacy of a vegan diet.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is teaching a client who plans to begin following vegan dietary guidelines. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse is conducting an admission assessment on a newborn. Which of the following findings should the nurse identify as an indication of sepsis?

A nurse is reviewing the medical history of a client who asks about the use of conjugated estrogen. The nurse should identify which of the following findings as a contraindication for the administration of this medication?

A nurse is preparing to perform a sterile wound irrigation and dressing change for a client. Which of the following actions by the nurse indicate break in surgical aseptic technique?

A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow-up care?

A nurse is assessing a client who is at 24 weeks of gestation during a routine prenatal exam. Which of the following findings should the nurse report to the provider?

A nurse is providing discharge teaching to the partner of a client who has a tracheostomy. Which of the following information should the nurse include in the teaching?