Patient Data

Exhibits

At 2000, the unlicensed assistive personnel (UAP) reported the client's vital signs as a temperature of 102.1° F (38.9° C) orally, a heart rate of 62 beats/minute, respirations of 19 breaths/minute, and a blood pressure of 124/68 mm Hg.

Which action(s) should the nurse take? Select all that apply

Attach the client to a cardiorespiratory monitor to measure the respiratory rate

Assure that the blood pressure cuff is the right size

Alert the healthcare provider once the abnormal finding is confirmed

Retake the temperature orally

Reassess the blood pressure

Measure the heart rate for a full 60 seconds

Answer and Explanation

Correct Answer : C,D,F

A. Attach the client to a cardiorespiratory monitor to measure the respiratory rate: The respiratory rate is within the normal range and does not require continuous monitoring at this stage unless other symptoms suggest deterioration.

B. Assure that the blood pressure cuff is the right size: The blood pressure is within normal limits and does not indicate an issue with the cuff size at this moment.

C. Alert the healthcare provider once the abnormal finding is confirmed: A temperature of 102.1° F (38.9° C) is a significant fever and could indicate worsening infection or an adverse reaction to the medication. Alerting the healthcare provider is essential for prompt evaluation and treatment adjustment.

D. Retake the temperature orally: Confirming the elevated temperature with a retake is crucial for accuracy. Temperature readings can sometimes be affected by factors like improper thermometer use or external influences.

E. Reassess the blood pressure: Blood pressure readings are stable and not indicative of any immediate issue requiring reassessment.

F. Measure the heart rate for a full 60 seconds: The heart rate of 62 beats/minute is on the lower side of normal, and measuring for a full minute will provide a more accurate assessment of the client’s heart rate and detect any irregularities.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B. Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C. Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D. Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

Correct Answer is ["40"]

Explanation

To determine the amount of suspension the child should receive per day, we first calculate the dosage per administration. Since the prescription is for 500 mg and the suspension is 250 mg/5 mL, the child needs 10 mL per dose (because 500 mg divided by 250 mg/mL equals 2, and 2 times 5 mL equals 10 mL).

As the prescription is four times a day, the child should receive 40 mL per day.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Correct Answer is B

Explanation

The nurse is preparing to administer a suspension ampicillin labeled, 250 mg/5 mL, to a child with impetigo. The prescription is for 500 mg four times a day. How many mL should the child receive per day? (Enter numeric value only.)

Correct Answer is ["40"]

Explanation

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Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.