A nurse is caring for a group of clients. Which of the following findings should the nurse report to the provider?
An adolescent who has a BP of 132/82 mm Hg
A 3-month-old infant who has a respiratory rate of 30/min
An 18-month-old toddler who has a heart rate of 68/min
A school-age child who has a rectal body temperature of 37.3° C (99.1° F)
The Correct Answer is C
A. A blood pressure of 132/82 mm Hg in an adolescent is within the normal range for their age group. It does not require immediate reporting to the provider.
B. A respiratory rate of 30 breaths per minute in a 3-month-old infant is within the expected (typically 25-40 breaths per minute).
C. A heart rate of 68 beats per minute in an 18-month-old toddler is below the normal range (typically 70-110 beats per minute) and should be reported g to the provider.
D. A rectal body temperature of 37.3° C (99.1° F) in a school-age child is within the normal range (typically 36.5-37.5° C or 97.7-99.5° F). It does not require immediate reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Toddlers with phenylketonuria (PKU) need to limit their intake of phenylalanine, an amino acid found in protein. Therefore, the toddler's protein consumption should be carefully controlled and monitored.
B. Foods high in iron do not need to be specifically limited for a child with PKU. Iron-rich foods are important for overall health and should be included in the diet.
C. Aspartame contains phenylalanine and should be avoided by individuals with PKU. PKU is a metabolic disorder that impairs the body's ability to break down phenylalanine, so it is important to limit phenylalanine intake.
D. This is correct. Foods containing milk products should be avoided, as they are a source of phenylalanine and can contribute to an excessive intake of this amino acid in a child with PKU. Instead, specialized medical foods low in phenylalanine are recommended.
Correct Answer is C
Explanation
A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.
B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.
C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.
D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.
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