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Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Electrocardiogram: Tall T wave and widened QRS complex

Blood pressure: 126/76 mm Hg

Basilar crackles

Urine output: 20 mL in the last hour

Respirations: 26 breaths/minute

Heart rate: 72 beats/minute

Oxygen saturation 98% on room air

A normal body temperature (98.9°F or 37.1°C orally).

Answer and Explanation

Correct Answer : B,F,G,H

A. An electrocardiogram with a tall T wave and widened QRS complex may indicate electrolyte imbalances or cardiac issues, which are not indicative of stabilization.

C. Basilar crackles can be a sign of pulmonary or cardiac issues and are not indicative of stabilization.

D. A urine output of 20 mL in the last hour may suggest reduced kidney function or hydration status and is not indicative of stabilization.

E. A respiratory rate of 26 breaths/minute may indicate respiratory distress and is not indicative of stabilization.

The assessment findings that suggest stabilization include:

A blood pressure within the normal range (126/76 mm Hg).

A heart rate within the normal range (72 beats/minute).

Oxygen saturation of 98% on room air, indicating adequate oxygenation.

A normal body temperature (98.9°F or 37.1°C orally).

These vital signs and clinical parameters are within normal ranges, suggesting that the client's condition is stable at this time.

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Correct Answer is B

Explanation

When advising a new mother in caring for a child with croup, the symptom that should be a priority concern to the telephone triage nurse is B.

Explanation:

A. A fever of 101.0°F (38.3°C) is a common symptom in many childhood illnesses, including croup, but it is not the primary concern when difficulty swallowing secretions is present.

B Difficulty swallowing secretions.

Croup is characterized by a barking cough and may also be associated with stridor (noisy breathing), hoarseness, and difficulty swallowing secretions. While all the symptoms mentioned can be concerning, difficulty swallowing secretions is a priority concern because it can potentially lead to respiratory distress if not managed appropriately. Thick secretions can cause airway obstruction, and prompt assessment and intervention are needed to ensure the child's airway remains clear and that the child is able to breathe effectively.

C. A barking cough, worse at night, is a classic symptom of croup and should be addressed, but difficulty swallowing secretions can have a more direct impact on the child's airway.

D. Crying often when nursing may be related to the discomfort caused by croup, but it is not as immediately concerning as difficulty swallowing secretions.

While the barking cough, hoarseness, and other croup symptoms should also be addressed, the priority is ensuring that the child is able to manage secretions effectively without respiratory distress. The telephone triage nurse should provide guidance to the mother on how to help the child manage these secretions and when to seek medical attention if the situation worsens.

A. Determine when the child last ate B. Measure the child's height and weight C. Perform a mini-mental exam on the child D. Locate and mark the pedal pulses E. Obtain a history of allergic reactions F. Document lying, sitting, and standing blood pressures

Correct Answer is ["A","D","E"]

Explanation

The correct answers are A, D, E.

Before the cardiac catheterization for a 3-year-old with a history of ventricular septal defect, the nurse's focused assessment should include the following:

A. Determine when the child last ate: Knowing when the child last ate is important because the procedure may require fasting, and the nurse needs to ensure that the child has adhered to the fasting guidelines.

D. Locate and mark the pedal pulses: Locating and marking the pedal pulses is essential to establish a baseline for assessing peripheral circulation, especially given the history of ventricular septal defect.

E. Obtain a history of allergic reactions: Obtaining a history of allergic reactions is important to ensure that there are no allergies or sensitivities that could impact the procedure or the use of any contrast materials during the cardiac catheterization.

The other options are not necessary components of the focused assessment in preparation for the cardiac catheterization:

B. Measure the child's height and weight: Measuring height and weight may be done at some point but is not a priority in the immediate pre-procedural assessment.

C. Perform a mini-mental exam on the child: A mini-mental exam may not be applicable or necessary in the pre-catheterization assessment of a 3-year-old.

F. Document lying, sitting, and standing blood pressures: Blood pressure variations in different positions are typically not relevant for this type of procedure, and it may not be practical or necessary for a 3-year-old.

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Exhibits Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

Correct Answer is B

Explanation

Correct Answer is ["A","D","E"]

Explanation

The nurse is teaching the parents about important dietary changes for their child who is newly diagnosed with celiac disease. Which foods should the nurse include in the list of allowed foods for this child?

The mother of an 11-year-old boy who has juvenile idiopathic arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting." Which information is most important for the nurse to provide this mother?

The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?

The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. Which information should the nurse provide?

Exhibits

Two days later, the nurse completes an assessment of the client. Which assessment findings indicate that the client has stabilized? Select all that apply.