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 C
Explanation
A. Drinking milk on an empty stomach is not recommended for individuals with lactose intolerance, as it can lead to more pronounced symptoms.
B. Flavored yogurts may contain additional sugars or additives that can exacerbate
symptoms in individuals with lactose intolerance. It is generally recommended to choose plain, unsweetened yogurt.
C. This is a correct instruction. There are various nondairy sources of calcium, such as fortified soy milk, almond milk, leafy green vegetables, and certain types of fish (like salmon and sardines).
D. Tolerability of plain milk versus flavored milk can vary from person to person. Some individuals may find one easier to tolerate than the other, but it is not a universal rule for everyone with lactose intolerance.
Correct Answer is C
Explanation
A. Placing the child in the Trendelenburg position is not necessary for tracheostomy care. In fact, this position is generally not recommended for routine tracheostomy care.
B. Sterile technique, not clean technique, should be used when changing the tracheostomy tube to reduce the risk of infection.
C. This is the correct action. Having the child flex his head can help prevent tension on the tracheostomy ties and ensure a secure and comfortable fit.
D. Full-strength hydrogen peroxide is too harsh and can cause irritation to the skin around the stoma. It is recommended to use normal saline or a mild soap and water solution for cleaning.
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