A nurse is caring for a 2-year-old child in an acute care setting. Which of the following vital signs require immediate notification to a primary care provider?
BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F)
BP 79/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38° C (100.4" F)
BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7° C (98.1° F)
BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6" C (99.7" F)
The Correct Answer is B
A. These vital signs are generally within expected ranges for a 2-year-old child.
B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.
C. These vital signs are within normal limits for a 2-year-old child.
D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A weight loss of 10% or more in infants within a short period is indicative of severe dehydration. The significant weight loss from 5 kg to 4.3 kg confirms this diagnosis.
B. The risk for fluid volume deficit would be noted if there were signs of potential dehydration, but in this case, the infant has already lost a significant amount of weight, confirming severe dehydration.
C. Failure to thrive is a diagnosis related to insufficient weight gain over time, rather than acute weight loss due to dehydration.
D. Malabsorption syndrome could contribute to chronic weight loss, but the acute loss in this case is more likely due to dehydration from diarrhea.
Correct Answer is A
Explanation
A. Acetaminophen is appropriate for managing mild discomfort post-procedure.
B. Tub baths are generally avoided for the first few days to prevent infection at the catheterization site; sponge baths are preferred.
C. Keeping the child home for 1 week might be excessive; follow the healthcare provider's specific instructions regarding activity and school return.
D. Clear liquids are typically offered as tolerated, but the primary concern post-procedure is monitoring the insertion site and ensuring the child rests adequately.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.