An assistive personnel tells the nurse that several client measurements were obtained with morning vital signs. Which of the following clients should the nurse plan to assess first?
A 6-year-old child who has glomerulonephritis and a blood pressure of 130/78 mm Hg
A 2-year-old child who has Kawasaki disease and a temperature of 39° C (102.2° F)
A 4-year-old child who has a closed-head injury and a heart rate of 60/min
An 8-year-old child who has type I diabetes mellitus and a respiratory rate of 26/min
The Correct Answer is C
Choice A reason: A blood pressure of 130/78 mm Hg in a 6-year-old with glomerulonephritis is elevated, but hypertension is an expected complication of glomerulonephritis. This requires monitoring and treatment but is not immediately life-threatening.
Choice B reason: A temperature of 39° C (102.2° F) in a 2-year-old with Kawasaki disease is concerning but not immediately life-threatening. Fever is common in Kawasaki disease, and antipyretics and supportive care are indicated.
Choice C reason: A heart rate of 60/min in a 4-year-old with a closed-head injury is bradycardic. Normal heart rate for this age is 80–120/min. Bradycardia in the context of a head injury can indicate increased intracranial pressure, which is a medical emergency requiring immediate intervention. This makes it the highest priority.
Choice D reason: A respiratory rate of 26/min in an 8-year-old with type I diabetes mellitus is slightly elevated but not critically abnormal. It could suggest early compensation for metabolic acidosis, but it is not as urgent as bradycardia with head injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The sterile field must always be set up at or above waist level to maintain sterility. Setting it below waist level increases the risk of contamination because the nurse cannot maintain constant visual control.
Choice B reason: Holding the bottle with the palm over the label while pouring prevents solution from running over the label, keeping it legible and dry. This is correct sterile technique and ensures safe handling of sterile solutions.
Choice C reason: Sterile items should be placed at least 2.5 cm (1 in) inside the sterile border. Placing them within 1 cm risks contamination because the edges of the sterile field are considered non-sterile.
Choice D reason: The lid of a sterile solution bottle should be placed face up on a clean surface, not within the sterile field. Placing it in the sterile field contaminates the area.
Correct Answer is C
Explanation
Choice A reason: Eggs contain protein and some vitamins but are not a significant source of calcium. They do not contribute meaningfully to calcium intake.
Choice B reason: Chicken is a good source of protein but contains negligible calcium. It is not recommended for increasing calcium intake.
Choice C reason: Spinach contains calcium and is a plant-based source of this mineral. Although it also contains oxalates that reduce calcium absorption, it is still considered a calcium-rich food and appropriate for dietary teaching.
Choice D reason: Raisins provide iron and fiber but are not a significant source of calcium. They do not contribute to bone health in the same way calcium-rich foods do.
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