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A nurse is caring for an 8-year-old child on an inpatient pediatric unit.

Exhibits
Click to highlight the findings that indicate the client requires immediate follow-up. To deselect a finding, click on the finding again

Body System

Findings

Integumentary

Skin feels cool to the touch.

Capillary refill 3 seconds in left foot

Dressing on left hand shows small amount of moisture through gauze.

Vital Signs

Blood pressure 102/50 mm Hg

Temperature 35.8° C (96.4° F)

Respiratory rate 20/min

Genitourinary

Output of 25 mL dark amber urine through catheter

Skin feels cool to the touch.

Capillary refill 3 seconds in left foot

Dressing on left hand shows small amount of moisture through gauze.

Blood pressure 102/50 mm Hg

Temperature 35.8° C (96.4° F)

Respiratory rate 20/min

Output of 25 mL dark amber urine through catheter

Answer and Explanation

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

Rationale for correct choices:

Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.

Rationale for incorrect choices:

Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

A. Assess the client’s breath sounds: Auscultation helps determine how well interventions like albuterol and oxygen are working. Detecting changes such as worsening wheezes, crackles, or diminished sounds ensures early recognition of complications. This is vital given the client’s chronic smoking history and respiratory distress.

B. Restrict the client’s fluid intake: Adequate hydration thins mucus, making it easier to clear. Unless there is heart or kidney failure, fluids should be encouraged. Restricting intake could worsen secretion retention and impair gas exchange.

C. Perform chest percussion and vibration: These techniques loosen mucus and promote clearance in clients with COPD or chronic bronchitis. Because the client has a productive cough and abnormal lung sounds, this intervention supports better airway patency. It also works well alongside bronchodilators for improved breathing.

D. Increase oxygen flow rate to 4 L/min: In clients with chronic CO₂ retention, too much oxygen can suppress respiratory drive. The current prescription of 2 L/min should be maintained unless the provider reassesses and orders changes based on ABGs.

E. Instruct the client to perform diaphragmatic breathing: This method enhances airflow to the lower lungs, reduces accessory muscle use, and improves oxygen exchange. For a COPD client, it helps conserve energy and improve ventilation. Combined with pursed-lip breathing, it strengthens respiratory efficiency.

F. Place the client in a supine position: Lying flat limits lung expansion and can worsen dyspnea in clients with lung disease. An upright or high-Fowler’s position promotes maximal ventilation and better oxygenation.

A. "Keep objects away from your center of gravity while lifting." B. "Keep your feet together to provide a tight base of support." C. "Tighten abdominal muscles to improve balance." D. "Bend at the waist when lifting objects from the floor."

Correct Answer is C

Explanation

A. "Keep objects away from your center of gravity while lifting.": Lifting objects away from the body increases strain on the back and risks injury. Objects should be kept close to the body to reduce musculoskeletal stress.

B. "Keep your feet together to provide a tight base of support.": A narrow stance decreases stability and increases the risk of losing balance. Proper lifting requires a wide, stable base with feet shoulder-width apart.

C. "Tighten abdominal muscles to improve balance.": Engaging the core stabilizes the spine, maintains proper posture, and helps prevent back injuries during lifting. This is an important ergonomic technique.

D. "Bend at the waist when lifting objects from the floor.": Bending at the waist places excessive strain on the lower back. Proper lifting technique involves bending at the knees and hips while keeping the back straight.

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Body System	Findings
Integumentary	Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze.
Vital Signs	Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min
Genitourinary	Output of 25 mL dark amber urine through catheter

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

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