A nurse is caring for a child who received an initial dose of antibiotics 20 min ago. Which of the following findings is the priority to report to the provider?

Maculopapular rash

Headache

Wheezing

Increased pulse

Answer and Explanation

The Correct Answer is C

Choice A reason:

A maculopapular rash may be an allergic reaction to the antibiotic. While this should be reported, wheezing is a more urgent concern.

Choice B reason:

A headache may be a side effect of the antibiotic, but it is not as urgent as wheezing.

Choice C reason:

Wheezing can indicate a potential serious allergic reaction or anaphylaxis to the antibiotic. This is the priority finding to report to the provider.

Choice D reason:

An increased pulse may be a side effect of the antibiotic, but it is not as urgent as wheezing.

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Correct Answer is A

Explanation

Choice A reason:

Diminished pulses can be indicative of decreased cardiac output, as it suggests that there may be a reduction in the volume of blood being pumped by the heart.

Choice B reason:

Extremities warm to touch is not necessarily indicative of decreased cardiac output. It may be related to other factors, such as ambient temperature or local blood flow.

Choice C reason:

Capillary refill of 2 seconds is within the normal range for a preschooler, and it is not a strong indicator of decreased cardiac output.

Choice D reason:

A blood pressure of 112/66 mm Hg is within the normal range for a preschooler and is not a strong indicator of decreased cardiac output.

A. Ensure the child's safety. B. Tell the child they are not at fault. C. Document the location of the child’s injuries D. Notify local law enforcement.

Correct Answer is A

Explanation

Choice A reason:

Ensuring the child's safety is the top priority. If the child is in immediate danger, steps must be taken to protect them.

Choice B reason:

While providing emotional support to the child is important, ensuring their physical safety takes precedence.

Choice C reason:

Documenting injuries is important for a comprehensive assessment and for legal purposes, but it should follow ensuring the child's immediate safety.

Choice D reason:

Notifying law enforcement may be necessary, but ensuring the child's immediate safety comes first.

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A nurse is caring for a child who received an initial dose of antibiotics 20 min ago. Which of the following findings is the priority to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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