During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?

Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks.

Measure the child's blood pressure three times during the visit and determine the highest of the readings.

Conduct a head-to-toe assessment and omit repeated blood pressures during the examination.

Take the blood pressure two more times during the visit and determine the average of the three readings.

Answer and Explanation

The Correct Answer is D

If a child's systolic blood pressure is greater than the 90th percentile during a routine clinic visit, the nurse should take the blood pressure two more times during the visit and determine the average of the three readings. This will provide a more accurate assessment of the child's blood pressure. Referring the child to the healthcare provider and scheduling an evaluation of blood pressure in two weeks

A. may be necessary if the child's blood pressure remains elevated, but it is not the next action that should be taken. Measuring the child's blood pressure three times during the visit and determining the highest of the readings

B. is not recommended because it may overestimate the child's blood pressure. Conducting a head-to-toe assessment and omitting repeated blood pressures during the examination

C. is not appropriate because it does not provide an accurate assessment of the child's blood pressure.

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Correct Answer is C

Explanation

During the initial phase of treatment for osteomyelitis, the nurse should instruct the child and parent to ensure that there is no weight bearing on the aﬀected extremity. This may require the use of assistive devices such as crutches or a wheelchair. Administering topical antibiotic therapy, providing passive range of motion exercises, and scheduling ice pack applications to the infected area are not appropriate interventions during the initial phase of treatment.

Topical antibiotics may be used later in the course of treatment, after the initial phase of intravenous antibiotics has been completed.

Passive range of motion exercises may be appropriate during the later phases of treatment to prevent joint contractures.

Ice pack applications may be appropriate for pain relief, but they are not a primary intervention for osteomyelitis.

A. Have the child blow a cotton ball and have the parent catch it. B. Place a toy in the child's hands while listening to the breath sounds. C. Oﬀer the child bubbles before the stethoscope is placed. D. Allow the child to use a stethoscope on a stuﬀed animal.

Correct Answer is D

Explanation

To ensure the cooperation of a preschooler during an assessment of lung sounds, the nurse can allow the child to use a stethoscope on a stuﬀed animal. This helps the child understand what is happening and feel more comfortable with the procedure. Having the child blow a cotton ball (A), placing a toy in the child's hands (B), and oﬀering bubbles (C ) may distract the child but do not directly involve them in the procedure.

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During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?

Correct Answer is C

Explanation

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

Correct Answer is D

Explanation

During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?

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