A nurse is caring for a 2-year-old child in an acute care setting.
Which of the following vital signs require immediate notification to a primary care provider?
BP 90/40 mm Hg, heart rate 135/min, respirations 32/min, and oral temperature of 38°C (100.4°F).
BP 88/45 mm Hg, heart rate 113/min, respirations 28/min, and oral temperature 37.6°C (99.7°F).
BP 85/50 mm Hg, heart rate 95/min, respirations 26/min, and axillary temperature of 36.7°C (98.1°F).
BP 90/52 mm Hg, heart rate 120/min, respirations 28/min, and axillary temperature of 37.3°C (99.1°F). . .
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale
A blood pressure of 90/40 mm Hg, heart rate of 135/min, respirations of 32/min, and an oral temperature of 38°C (100.4°F) indicate potential signs of sepsis or another serious condition. The elevated heart rate and respiratory rate, along with the fever, suggest an infection that requires immediate medical attention.
Choice B rationale
While the vital signs in this option are slightly elevated, they are not as concerning as those in Choice A. The heart rate and respiratory rate are within acceptable ranges for a 2-year-old, and the temperature is only slightly elevated.
Choice C rationale
The vital signs in this option are within normal ranges for a 2-year-old child. There is no immediate cause for concern based on these vital signs.
Choice D rationale
The vital signs in this option are also within acceptable ranges for a 2-year-old child. While the heart rate is slightly elevated, it is not as concerning as the vital signs in Choice A. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
The correct answers are Choices A, C, and E.
Choice A rationale
Daytime symptoms occurring more than twice a week is an expected finding in mild persistent asthma. This indicates that the asthma is not well-controlled and requires regular use of a controller medication.
Choice B rationale
Nighttime symptoms occurring approximately twice a month is more characteristic of intermittent asthma, not mild persistent asthma.
Choice C rationale
Minor limitations with normal activity are expected in mild persistent asthma. This indicates that the asthma is affecting the child’s daily activities to some extent.
Choice D rationale
Symptoms that are continuous throughout the day are indicative of severe persistent asthma, not mild persistent asthma.
Choice E rationale
A peak expiratory flow (PEF) greater than or equal to 80% of the predicted value is an expected finding in mild persistent asthma. This indicates that the child’s lung function is relatively well-preserved. .
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Droplet precautions are used for infections spread through large respiratory droplets, such as influenza, but are not sufficient for measles.
Choice B rationale
Airborne precautions are necessary for measles, as it is spread through small droplets that can remain suspended in the air and travel over long distances.
Choice C rationale
Contact precautions are used for infections spread through direct contact with the patient or their environment, such as MRSA, but are not sufficient for measles.
Choice D rationale
A protective environment is used for patients with compromised immune systems to protect them from infections, not for preventing the spread of infections like measles.
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