A nurse is teaching a newly licensed nurse about assessing children's blood pressure. Which of the following statements made by the newly licensed nurse demonstrates an understanding of the teaching?

"Cuffs are recommended to be 6 to 15 cm or 2 to 6 inches for school-aged children."

“The cuff should fit loosely around the child's arm."

"Blood pressure measurement is taken over the brachial artery using a manual blood pressure cuff.”

"Routine blood pressure measurements should begin around 1 year of age."

Answer and Explanation

The Correct Answer is C

A. Cuff size recommendations vary based on the child’s arm circumference, not a specific range for all school-aged children.

B. The cuff should fit snugly around the child's arm, not loosely, to obtain an accurate reading.

C. Blood pressure is typically measured over the brachial artery using a manual or automated cuff.

D. Routine blood pressure screening usually begins at age 3 unless there are specific indications to begin earlier.

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Correct Answer is D

Explanation

A. Cardiac enzymes are not typically monitored in relation to nutritional status.

B. Blood coagulation tests are not directly related to general nutrition.

C. Arterial blood gases assess respiratory and metabolic function, not nutrition.

D. A complete blood count (CBC) can help identify nutritional deficiencies, such as anemia due to iron or vitamin deficiencies.

A. An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hr and ate 90% of their meals B. A 15-year-old adolescent who had a laparoscopic appendectomy 30 hr ago, rates their pain a 3 on a scale of 1 to 10, and is preparing for discharge this morning C. A 3-year-old toddler who aspirated several sunflower seeds and continues to cough with an O. saturation of 91% D. A 6-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hr ago E. Child's statements with parent input

Correct Answer is C

Explanation

A. The 18-month-old shows signs of improving hydration status, evidenced by adequate wet diapers and food intake. This client is stable.

B. The adolescent with mild postoperative pain and preparing for discharge is stable and does not require immediate attention.

C. The toddler's low oxygen saturation (91%) and continued coughing indicate potential airway obstruction or impaired gas exchange, which requires immediate assessment and intervention to prevent respiratory failure.

D. Although the 6-year-old with asthma should be monitored, their last use of a rescue inhaler 16 hours ago suggests they are not in acute distress.

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A nurse is teaching a newly licensed nurse about assessing children's blood pressure. Which of the following statements made by the newly licensed nurse demonstrates an understanding of the teaching?

Nursing Test Bank

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