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

Have the child blow a cotton ball and have the parent catch it.

Place a toy in the child's hands while listening to the breath sounds.

Oﬀer the child bubbles before the stethoscope is placed.

Allow the child to use a stethoscope on a stuﬀed animal.

Answer and Explanation

The Correct Answer is D

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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Correct Answer is A

Explanation

For an eight-month-old infant with heart failure, the nurse should withhold digoxin if the infant's apical pulse is less than 90 beats/minute and notify the healthcare provider. In this case, the infant's apical pulse is 88 beats/minute, so the nurse should withhold the digoxin and notify the healthcare provider.

Furosemide ( B), hydralazine (C), and enalapril (D) do not have specific parameters for withholding based on the infant's vital signs.

A. Change position every 2 hours. B. Monitor peripheral pulses and sensation in the right leg. C. Cleanse pin sites as prescribed. D. Assess skin for redness and signs of tissue breakdown.

Correct Answer is B

Explanation

When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the aﬀected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.

Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.

Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

When providing care for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

Correct Answer is B

Explanation

The nurse is assessing a preschool-aged child who presents with ﬂank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?

A six-year-old girl is being admited to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?

A 7-year-old child is admited to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inﬂamed conjunctiva. The child receives a prescription for an ophthalmic anti-infective ointment. Which instruction should the nurse provide the child's caregivers during discharge education?

When developing a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the client to eat a source of sugar if which symptom occurs?

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?