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Patient Data

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.

IV site without redness or swelling

Temperature: 98.8° F (37.1° C)

Respirations: 28 breaths/minute

Heart rate: 92 beats/minute

Taking shallow breaths

Alert and oriented to person, place, time and situation

Pain 8 on a 0 to 10 scale

Blood pressure: 138/82 mm Hg

Answer and Explanation

Correct Answer : C,E,G

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

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Correct Answer is B

Explanation

A. A potty chair should be brought from home to maintain the current level of toileting skills: While familiar items can offer comfort, regression in toileting is typically temporary and does not require special equipment to preserve skills.

B. Children usually resume their toileting behaviors when they leave the hospital: Hospitalization is a stressful event for preschoolers, and temporary regression in toileting is common. Reassuring parents that the child is likely to return to previous toileting behaviors once home helps reduce anxiety and supports normal developmental expectations.

C. Diapering will be provided since hospitalization is stressful to preschoolers: Diapering may be used for convenience or safety, but presenting it as necessary for all hospitalized children may cause unnecessary concern. It does not address the expected return to prior skills.

D. A retraining program will need to be initiated when the child returns home: Most children spontaneously resume previous toileting abilities without formal retraining. Only persistent regression after discharge would warrant intervention.

Correct Answer is ["1.3"]

Explanation

Convert the infant's weight from pounds (lb) to kilograms (kg).

Given weight = 22 lb

Conversion factor = 1 kg = 2.2 lb

Weight (kg) = (Weight in lb / 2.2 lb/kg)

= (22 / 2.2)

= 10 kg.

Calculate the total daily dose in milligrams (mg/day).

Prescribed dose = 20 mg/kg/day

Total Daily Dose (mg/day) = Weight (kg) x Dose (mg/kg/day)

= 10 kg x 20 mg/kg/day = 200 mg/day.

Calculate the single dose in milligrams (mg/dose).

Frequency = every 8 hours (3 doses per day)

Single Dose (mg/dose) = (Total Daily Dose / Number of doses per day)

= (200 mg / 3)

= 66.67 mg.

Calculate the volume in milliliters (mL) to administer per dose.

Available concentration = 250 mg per 5 mL

Volume (mL/dose) = (Single Dose (mg) / Available concentration (mg)) x Available volume (mL)

= (66.67 mg / 250 mg) x 5 mL

= 1.333... mL.

Round the answer to the nearest tenth.

= 1.3 mL.

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Patient Data Exhibits The nurse is reviewing the client's initial assessment findings. Which assessment findings require follow-up? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents?

Correct Answer is B

Explanation

Correct Answer is ["1.3"]

Explanation

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Patient Data

Exhibits

The nurse is reviewing the client's initial assessment findings.
Which assessment findings require follow-up? Select all that apply.