Patient's data
Which assessment findings require follow up by the nurse? Select all that apply.
Skin pale and diaphoretic
Respiratory rate 36 breaths/minute
Blood pressure 140/86 mm Hg
Temperature 101.1° F (38.4" C) orally
Bilateral basilar crackles
Bilateral radial pulses bounding
Heart rate 117 beats/minute and irregular
Oxygen saturation 98% on room air
Correct Answer : A,B,C,D,E,G
A. Skin pale and diaphoretic: These can be signs of dehydration, infection, or other conditions.
B. Respiratory rate 36 breaths/minute - This is elevated, especially for a child, indicating potential respiratory distress or infection, particularly given the patient's history and current fever.
C. Blood pressure 140/86 mm Hg - This is high for a 7-year-old and could indicate fluid overload or other complications related to his chronic kidney disease.
D. Temperature 101.1° F (38.4° C) orally - Continued fever despite antipyretic treatment suggests ongoing infection or inflammation needing further evaluation.
E. Bilateral basilar crackles - This could suggest fluid in the lungs (pulmonary edema), which is critical given the patient's possible fluid overload and high blood pressure.
F. Bilateral bounding radial pulses is not necessarily a cause of concern in the above case.
G. Heart rate 117 beats/minute and irregular - An elevated and irregular heart rate in a child is concerning and could indicate cardiovascular stress or electrolyte imbalances, which need addressing given his elevated potassium levels.
H. Oxygen saturation 98% on room air: Normal oxygen saturation suggests adequate gas exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["22"]
Explanation
To calculate the drip rate for an IV, you can use the formula: (Volume to be infused (mL) x Drop factor (gtt/mL)) / Time (min). For the prescribed 1 unit of PRBC at 350 mL to be infused over 4 hours with a drop factor of 15 gtt/mL, the calculation would be: (350 mL x 15 gtt/mL) / (4 hours x 60 minutes/hour). This simplifies to (5250 gtt) / (240 min), which equals 21.875 gtt/min. When rounded to the nearest whole number, the nurse should regulate the infusion to 22 gtt/min.
Correct Answer is A
Explanation
A. If the PN suspects an error in a prescription, especially regarding a child's dosage, it's imperative to communicate concerns to the healthcare provider for clarification and potential adjustment.
B. While involving another nurse might provide a second opinion, it's crucial to involve the prescriber to rectify any potential prescription errors.
C. The prescription should be confirmed with the healthcare provider before any medication is dispensed or administered.
D. While seeking information from peers is valuable, this situation calls for direct clarification from the prescriber to ensure proper dosing for the child.
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