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A nurse is caring for a toddler admitted to the hospital.

Exhibits

Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again.

Body Systems

Findings

Respiratory

Respiratory rate 26/min

Cardiovascular

Heart rate 112/min

Capillary refill 4 seconds

Gastrointestinal

Hyperactive bowel sounds

Integumentary

Diaper area reddened with erythema noted

Extremities cool

Reports no tears

Neurologic

Lethargic

Capillary refill 4 seconds

Hyperactive bowel sounds

Diaper area reddened with erythema noted

Extremities cool

Reports no tears

Lethargic

Respiratory rate 26/min

Heart rate 112/min

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Capillary refill 4 seconds: A prolonged capillary refill time of more than 2 seconds may indicate poor perfusion, possibly due to dehydration or circulatory compromise. This warrants immediate follow-up to assess for potential dehydration or shock.

Hyperactive bowel sounds: This may indicate gastrointestinal distress, such as diarrhea or irritation.

Diaper area erythema: Diaper rash is common in toddlers, particularly with diarrhea. Extremities cool: Cool extremities can be a sign of poor peripheral circulation, often associated with dehydration or developing hypovolemic shock. Immediate intervention is needed to address potential circulatory issues.

Reports no tears: The absence of tears, especially in a toddler, may suggest significant dehydration. This is a concerning sign and requires immediate follow-up to assess the child's hydration status and consider interventions, such as IV fluids or electrolyte management.

Lethargic: The child's lethargy, especially after vomiting and with decreased responsiveness, raises concern for potential dehydration, electrolyte imbalance, or a worsening condition. Lethargy in a toddler requires prompt evaluation and intervention to prevent further deterioration.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Blood pressure – The client's blood pressure of 114/56 mm Hg is within an acceptable range and does not indicate hypotension or hypertension.

B. Temperature – A temperature of 38.6°C (101.5°F) is indicative of fever, which is concerning in a client undergoing chemotherapy due to their increased risk of infection (febrile neutropenia). Prompt evaluation and intervention are necessary to prevent sepsis.

C. Potassium level – The client's potassium level of 3.6 mEq/L is within the normal range (3.5 to 5 mEq/L) and does not require immediate intervention.

D. WBC count – The client's WBC count has decreased to 3,800/mm³, which is below the normal range (5,000 to 10,000/mm³), indicating leukopenia. This places the client at a higher risk for infection, requiring close monitoring and potential interventions.

E. Breath sounds – The presence of crackles at the lung bases suggests possible pulmonary complications, such as fluid overload, infection (e.g., pneumonia), or early signs of acute respiratory distress syndrome (ARDS). This finding warrants further assessment and intervention.

A. Encourage the client to avoid wearing shoes at home. B. Place a throw rug over electrical cords. C. Ensure that area rugs have rubber backs. D. Mark the edges of the doorway to the house with tape.

Correct Answer is C

Explanation

A. Wearing well-fitted shoes at home helps prevent slips and falls.

B. Placing throw rugs over electrical cords increases the risk of tripping.

C. Area rugs with rubber backs prevent slipping, reducing the risk of falls in a postoperative client.

D. Marking doorways with tape is not necessary for a client after knee replacement and may be more applicable for clients with visual impairments.

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Body Systems	Findings
Respiratory	Respiratory rate 26/min
Cardiovascular	Heart rate 112/min Capillary refill 4 seconds
Gastrointestinal	Hyperactive bowel sounds
Integumentary	Diaper area reddened with erythema noted Extremities cool Reports no tears
Neurologic	Lethargic

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the client's electronic medical record. Exhibits Which of the following findings require follow up? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

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