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 A
Explanation
A. This statement indicates understanding. Giving water after administering digoxin helps ensure that the medication is swallowed and reaches the stomach, which is important for proper absorption.
B. Giving digoxin with foods high in fiber is not a specific instruction for administering this medication. It is important to follow the healthcare provider's specific dosing
instructions.
C. If a child vomits after taking digoxin, the parent should not give another dose. They should wait until the next scheduled dose. Double dosing can lead to overdose.
D. Mixing digoxin with juice is not recommended, as it may affect the absorption of the medication. It is best to give digoxin with a small amount of water.
Correct Answer is D
Explanation
A. Oliguria (decreased urine output) is not typically associated with hypokalemia. It can be a symptom of other electrolyte imbalances or kidney dysfunction.
B. Hypertension (high blood pressure) is not a typical finding in a child with hypokalemia. Low potassium levels are more likely to be associated with cardiac dysrhythmias and hypotension.
C. Hyperactive bowel sounds are not directly related to hypokalemia. They can occur in various gastrointestinal conditions, but they are not a specific indicator of potassium
levels.
D. This is the correct answer. Hypokalemia (low potassium levels) can lead to decreased neuromuscular excitability, which can result in hyporeflexia (reduced reflexes). This is an important neurological sign associated with low potassium levels.
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