When measuring a 6-month-old baby in the hospital for seizures, the nurse obtains a head circumference that is up 1 cm from the last measurement one week ago. The nurse re-measures and gets the same number What is the best next step?
Assume you made a mistake and report out the same head circumference as the before
Take Vital Signs
Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure
Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.
The Correct Answer is C
A. Assume you made a mistake and report out the same head circumference as before.
Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.
Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.
B. Take Vital Signs.
Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.
Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.
C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.
Correct Explanation: This is the best next step.
Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.
D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.
Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.
Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5.625"]
Explanation
To calculate the dose of amoxicillin for the toddler:
Step 1: Convert the toddler's weight from pounds to kilograms.
33 lb ÷ 2.2 (lb to kg conversion factor) = approximately 15 kg
Step 2: Calculate the total daily dose of amoxicillin.
Dose = 30 mg/kg/day × 15 kg = 450 mg/day
Step 3: Divide the total daily dose into equal doses every 12 hours.
450 mg/day ÷ 2 doses = 225 mg/dose
Step 4: Calculate the amount of amoxicillin suspension needed for each dose.
The available concentration is 200 mg/5 mL, so for 225 mg, you would use the proportion:
225 mg : 200 mg = x mL : 5 mL
Cross-multiplying: x = (225 mg × 5 mL) / 200 mg ≈ 5.625 mL
Therefore, the nurse should administer approximately 5.625 mL of amoxicillin suspension for each dose.
Correct Answer is B
Explanation
A. Maintain a saline-lock:
Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Check the child's daily weight:
Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
C. Place the child on a no-salt-added diet:
While dietary modifications can be important for managing various health conditions, including kidney issues, this is not the top priority in this situation. Reducing salt intake can help manage fluid retention, but it is not the nurse's priority action at this moment.
D. Educate the parents about potential complications:
Patient education is crucial, especially in chronic conditions, but in this acute care scenario, the nurse's immediate priority is to address the child's needs. Educating parents about potential complications should be done, but it's not the most immediate action.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.