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A nurse is assisting an infant who has respiratory syncytial virus.
For which of the following findings should the nurse intervene?

Brisk capillary refill

Tachypnea

Rhinorrhea

Coughing

Answer and Explanation

The Correct Answer is B

Choice A rationale

Brisk capillary refill is a normal finding and does not require intervention.

Choice B rationale

Tachypnea, or rapid breathing, is a common symptom of respiratory syncytial virus (RSV) infection in infants. It can indicate that the infant is having difficulty breathing and needs immediate intervention.

Choice C rationale

Rhinorrhea, or a runny nose, is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.

Choice D rationale

Coughing is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.

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Correct Answer is D

Explanation

Choice A rationale

Performing the examination once every other month is not the recommended frequency. It is generally recommended that males perform a testicular self-examination monthly.

Choice B rationale

Notifying your provider if your testes are firm and egg-shaped may not be necessary, as this is generally considered a normal characteristic of testes. However, any changes in size, shape, or consistency should be reported.

Choice C rationale

Waiting a month after feeling a hard lump is not recommended. If a hard lump is detected during a self-

examination, it should be reported to a healthcare provider immediately, as it could be a sign of testicular cancer.

Choice D rationale

Performing the examination following a warm shower is recommended. The warmth relaxes the scrotum, making it easier to examine the testicles.

A. Weak pedal pulse distal to the site B. Blood pressure 102/58mm Hg C. Bilateral cool extremities D. Serum glucose 90mg/dL

Correct Answer is A

Explanation

Choice A rationale

A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.

Choice B rationale

A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.

Choice C rationale

Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.

Choice D rationale

A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.

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A nurse is assisting an infant who has respiratory syncytial virus.For which of the following findings should the nurse intervene?

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A nurse is assisting an infant who has respiratory syncytial virus.
For which of the following findings should the nurse intervene?