A nurse is conducting discharge teaching to parents about the care of their infant after cardiac surgery. The nurse instructs the parents to notify the physician of what conditions occur. (Select all that apply.).
Respiratory rate of 36 breaths/minute at rest.
Appetite slowly increasing.
Temperature above 37.7° C (100° F).
New, frequent coughing.
Turning blue or bluer than normal.
Correct Answer : A,C,D,E
The correct answer is choices A, C, D, and E.
Choice A rationale:
A respiratory rate of 36 breaths/minute at rest is concerning in a pediatric client, as it may indicate respiratory distress or an underlying respiratory condition.
Choice B rationale:
An increasing appetite is generally a positive sign and not typically concerning unless accompanied by other symptoms.
Choice C rationale:
A temperature above 37.7° C (100° F) is concerning as it indicates fever, which could be a sign of infection or other medical conditions.
Choice D rationale:
New, frequent coughing is concerning as it may indicate respiratory infections, asthma, or other respiratory issues.
Choice E rationale:
Turning blue or bluer than normal (cyanosis) is a serious symptom indicating inadequate oxygenation and requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale:
The cuff labeled "toddler" is an appropriate criterion for selecting the right-sized blood pressure cuff for a 2-year-old boy. Pediatric blood pressure cuffs are available in different sizes, and using a cuff specifically labeled for toddlers ensures a proper fit and accurate blood pressure measurement.
Choice B rationale:
The cuff bladder width being approximately 40% of the circumference of the upper arm is a correct criterion. Using a cuff with an appropriate width ensures that the cuff covers a significant portion of the upper arm, allowing for accurate blood pressure measurement. A cuff that is too narrow or too wide can lead to inaccurate readings.
Choice C rationale:
The cuff bladder length covering 80% to 100% of the circumference of the upper arm is an incorrect criterion. The length of the cuff bladder should cover about 80% of the upper arm's circumference, not 80% to 100%. Using a cuff that is too long can result in falsely low blood pressure readings.
Choice D rationale:
The cuff bladder covering 50% to 66% of the length of the upper arm is an incorrect criterion. The bladder width, which covers the circumference of the upper arm, is more critical than the length. The width should be approximately 40% of the upper arm's circumference for accurate blood pressure measurement in children.
Correct Answer is B
Explanation
Choice A rationale:
Preventing the spread of illness to others is not the primary focus when teaching a mother about ulcerative colitis. Ulcerative colitis is a chronic inflammatory bowel disease and is not contagious. The primary focus of education should be related to managing the child's symptoms and improving their quality of life.
Choice B rationale:
Nutritional guidance and preventing constipation are essential aspects of managing ulcerative colitis. Proper nutrition helps support the child's overall health and well-being. Additionally, preventing constipation is crucial in managing symptoms and reducing discomfort for children with ulcerative colitis.
Choice C rationale:
Teaching daily use of enemas may be relevant in specific cases or during acute flare-ups, but it is not a general teaching point for all children with ulcerative colitis. Enema usage should be based on the healthcare provider's recommendation and tailored to the individual child's needs.
Choice D rationale:
Coping with stress and avoiding triggers is important in managing ulcerative colitis. Stress and certain triggers can exacerbate symptoms and lead to flare-ups. Teaching coping mechanisms and identifying triggers can help the child and their family manage the condition effectively.
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