A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?
"I am going to listen to your heart."
"Can I listen to your lungs?"
"I am going to take your blood pressure now."
"Can you stand very still while I feel how warm you are?"
The Correct Answer is A
A. “I am going to listen to your heart.”: This is the correct answer. It is a clear, simple statement that informs the child about what is going to happen. It is important to use language that is appropriate for the child’s age and development.
B. “Can I listen to your lungs?”: While this is a polite way to ask for consent, it might confuse a toddler who may not understand what “lungs” are.
C. “I am going to take your blood pressure now.”: This statement might be too complex for a toddler to understand. It’s better to use simpler language.
D. “Can you stand very still while I feel how warm you are?”: This statement might be confusing for a toddler. It’s better to use clear and direct language.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["240"]
Explanation
To calculate the total fluid intake, we need to convert all measurements to the same unit. In this case, we’ll convert everything to milliliters (mL).
1 cup = 240 mL 1 ounce (oz) = 30 mL
So, the child’s fluid intake is:
Juice: 1/2 cup = 120 mL
Gelatin: 3 oz = 90 mL
Ginger ale: 1 oz = 30 mL
Adding these together gives:
120 mL (juice) + 90 mL (gelatin) + 30 mL (ginger ale) = 240 mL
Therefore, the nurse should record the child’s fluid intake as 240 mL.
Correct Answer is C
Explanation
A. Place the infant in an infant seat for 2 hr following the procedure: This is not typically necessary after a lumbar puncture. The infant should be kept flat for several hours after the procedure to reduce the risk of headache and leakage of cerebrospinal fluid.
B. Keep the infant NPO for 6 hr prior the procedure: This is not typically required for a lumbar puncture. The procedure does not involve the gastrointestinal tract, so there is no need for the infant to be NPO (nothing by mouth).
C. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure: This is the correct answer. A eutectic mixture of local anesthetics (EMLA) can be applied to the skin prior to the procedure to help numb the area and reduce pain.
D. Hold the infant’s chin to his chest and knees to his abdomen during the procedure: This position is typically used for older children and adults during a lumbar puncture. For infants, the procedure is usually performed with the infant lying on their side, with their back curved and their knees drawn up toward their chest. This position helps to open up the spaces between the vertebrae and make the procedure easier.
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