The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal?
Answer Choices:
A Nontender.
B Bulges.
C Tenderness.
D Thrill.
Answer: A Nontender.
An infant with respiratory syncytial virus (RSV) has fever, rhinorrhea, coughing, and sneezing. Which finding indicates acute respiratory distress?
Answer Choices:
A Respiratory rate 35/minute.
B Bilateral bronchial breath sounds.
C Diaphragmatic respirations.
D Flaring of the nares.
Answer: D Flaring of the nares.
A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling while leaning forward when sitting. Which action should the nurse prepare the child for next?
Answer Choices:
A Schedule the child for a STAT MRI of the neck.
B Obtain bedside trays for intubation or tracheotomy by the healthcare provider.
C Begin prescribed intravenous antibiotic administration.
D Provide a nebulizer treatment with bronchodilators.
Answer: B Obtain bedside trays for intubation or tracheotomy by the healthcare provider.
A 9-year-old with appendicitis reports sudden relief in abdominal pain. Which action should the nurse take first?
Answer Choices:
A Document the client’s relief of pain.
B Give prescribed intravenous antibiotics.
C Inquire about the client’s last meal.
D Contact the healthcare provider.
Answer: D Contact the healthcare provider.
The nurse is assessing the lung sounds of a preschooler. Which action ensures the child’s cooperation?
Answer Choices:
A Allow the child to use a stethoscope on a stuffed animal.
B Have the child blow a cotton ball and have the parent catch it.
C Place a toy in the child’s hands while listening.
D Offer the child bubbles before the stethoscope is placed.
Answer: A Allow the child to use a stethoscope on a stuffed animal.
The nurse is administering a treatment to a child experiencing an asthma attack. The child is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid base imbalance?
Answer Choices:
A Metabolic alkalosis.
B Respiratory alkalosis.
C Respiratory acidosis.
D Metabolic acidosis.
Answer: B Respiratory alkalosis.
Insulin therapy is initiated for a 12-year-old with diabetic ketoacidosis (DKA). Which action is most important?
Answer Choices:
A Demonstrate insulin pen to parents.
B Monitor serum glucose for infusion adjustment.
C Consult about use of insulin detemir.
D Determine compliance schedule for NPH insulin.
Answer: B Monitor serum glucose for adjustment in infusion rate of regular insulin.
The parent of a one-month-old infant calls to report the back of the infant’s head is flat. How should the nurse respond?
Answer Choices:
A Turn the infant on the left side when sleeping.
B Place a small pillow under the infant’s head.
C Position the infant on the stomach occasionally when awake and active.
D Prop the infant in a sitting position with a cushion.
Answer: C Position the infant on the stomach occasionally when awake and active.
A 10-year-old reports headaches, stomach aches, and difficulty sleeping for three weeks. Which intervention should the nurse implement?
Answer Choices:
A Ask the student to describe a typical day at school.
B Counsel parents to pay more attention.
C Compare vital signs over three weeks.
D Conduct a complete neurological assessment.
Answer: A Ask the student to describe a typical day at school.
The nurse is caring for an infant admitted with dehydration, irritability, signs of extreme hunger, and a palpable olive-like mass in the upper right abdominal quadrant. When feeding the infant, the nurse should monitor for which development?
Answer Choices:
A Coffee-ground emesis.
B Arched back.
C Frequent pauses.
D Projectile vomiting.
Answer: D Projectile vomiting.