The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

Have the child blow a cotton ball and have the parent catch it.

Place a toy in the child's hands while listening to the breath sounds.

Oﬀer the child bubbles before the stethoscope is placed.

Allow the child to use a stethoscope on a stuﬀed animal.

Answer and Explanation

The Correct Answer is D

To ensure the cooperation of a preschooler during an assessment of lung sounds, the nurse can allow the child to use a stethoscope on a stuﬀed animal. This helps the child understand what is happening and feel more comfortable with the procedure. Having the child blow a cotton ball (A), placing a toy in the child's hands (B), and oﬀering bubbles (C ) may distract the child but do not directly involve them in the procedure.

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Correct Answer is C

Explanation

Infants with congenital heart defects may have difficulty with feeding due to increased eﬀort required to breathe and feed at the same time. This can lead to poor weight gain and dehydration. Thus, it is important for the nurse to report any signs of poor feeding or oral intake to the healthcare provider. While audible heart murmur (choice A)and a high heart rate (choice B)are expected findings in infants with congenital heart defects, they do not necessarily indicate a need for immediate intervention. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours (choice D)may actually be a positive finding in an infant with a congenital heart defect, but it is not as important to report as poor oral intake and suckling eﬀort.

A. Ask the boy to describe a typical day at school. B. Compare the child's vital signs over the past three weeks. C. Conduct a complete neurological assessment. D. Counsel the parents to pay more attention to the child.

Correct Answer is A

Explanation

The boy's reported symptoms may indicate stress or anxiety related to his school experience. By asking the boy to describe a typical day at school, the nurse can gather information about the child's interactions with teachers and peers, academic performance, and any other potential sources of stress. This information can be used to develop an appropriate plan of care that addresses the child's emotional and physical needs.

Comparing vital signs or conducting a neurological assessment may not provide useful information in this case, and counseling the parents to pay more attention to the child is not a recommended intervention without first identifying the underlying cause of the child's symptoms.

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The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

Correct Answer is A

Explanation

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