Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse at a pediatric clinic is checking the vital signs of a 2-week-old infant. Which of the following findings is outside of the expected reference range?
A. Respiratory rate 68/min.
This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.
B. BP 64/42 mm Hg.
Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.
C. Axillary temperature 36.6° C (97.9° F).
Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).
D. Apical heart rate 124/min.
Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.
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Full Explanation
This is outside of the expected reference range for a 2-week-old infant, which is 30 to 60 breaths per minute. A respiratory rate higher than 60 breaths per minute can indicate respiratory distress or infection.
Choice B is wrong because BP 64/42 mm Hg is within the normal range for a 2-week-old infant, which is 65 to 85/45 to 55 mm Hg.
Choice C is wrong because Axillary temperature 36.6° C (97.9° F) is within the normal range for a 2-week-old infant, which is 36.5 to 37.5° C (97.7 to 99.5° F).
Choice D is wrong because Apical heart rate 124/min is within the normal range for a 2-week-old infant, which is 110 to 160 beats per minute.
Similar Questions
A nurse is collecting data from an adolescent client who takes digoxin.
The nurse should monitor the client for which of the following adverse effects?
A. Yellow Sclera.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
B. Blurred vision.
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
C. Frequent swallowing.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin. It can be a sign of dysphagia or throat irritation.
D. Bleeding gums.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder. Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
Full Explanation
Blurred vision is a common adverse effect of digoxin that affects the eyes and the central nervous system. It can also cause yellow or green vision, halos around lights, and night blindness.
Choice A is wrong because yellow sclera is not an adverse effect of digoxin. It can be a sign of jaundice or liver disease.
Choice C is wrong because frequent swallowing is not an adverse effect of digoxin.
It can be a sign of dysphagia or throat irritation.
Choice D is wrong because bleeding gums is not an adverse effect of digoxin. It can be a sign of gingivitis or coagulation disorder.
Other adverse effects of digoxin include nausea, vomiting, diarrhea, lower stomach pain, dizziness, drowsiness, headache, weakness, confusion, depression, anxiety, hallucinations, expressed fear of impending death, rash, weight loss, loss of appetite, and various cardiac arrhythmias.
Some of these effects can indicate digoxin toxicity and require immediate medical attention.
Normal ranges for serum digoxin levels are 0.5 to 2 ng/mL for adults and 0.8 to 2 ng/mL for children.
Serum digoxin levels should be monitored regularly to avoid overdose or underdose.
A nurse is reinforcing teaching with a newly licensed nurse about delegating tasks to assistive personnel (AP).
Which of the following task-specific information should the nurse identify as a contraindication to delegating a task to an AP?
A. The task involves making ongoing judgments about client data.
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
B. The task is within the AP’s range of function to perform.
Choice B is wrong because the task is within the AP’s range of function to perform. This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
C. The task can be performed in the same manner for most clients.
Choice C is wrong because the task can be performed in the same manner for most clients. This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
D. The task requires a specific sequence of steps.
Choice D is wrong because the task requires a specific sequence of steps. This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
Full Explanation
The task involves making ongoing judgments about client data. This is a contraindication to delegating a task to an AP because the AP is not trained or authorized to make clinical decisions or assessments. The nurse is responsible for evaluating the client’s condition and needs, and delegating only tasks that are within the AP’s scope of practice and do not require critical thinking.
Choice B is wrong because the task is within the AP’s range of function to perform.
This is a criterion for delegating a task to an AP, not a contraindication. The nurse should ensure that the AP has the necessary skills and knowledge to perform the task safely and effectively.
Choice C is wrong because the task can be performed in the same manner for most clients.
This is also a criterion for delegating a task to an AP, not a contraindication. The nurse should delegate tasks that are routine, standardized, and have predictable outcomes.
Choice D is wrong because the task requires a specific sequence of steps.
This is not a contraindication to delegating a task to an AP, as long as the AP is competent and familiar with the procedure. The nurse should provide clear instructions and expectations for the task, and monitor the AP’s performance.
A nurse is collecting data from a 24-month-old toddler during an annual physical examination.
Which of the following findings should the nurse report to the provider?
A. Can draw a circle.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
B. Has a vocabulary of four words.
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
C. Jumps with both feet.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
D. Weighs 12 kg (26.5 Ib).
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.
Full Explanation
Has a vocabulary of four words. This is because a 24-month-old toddler should be able to speak about 50 or more words and use simple phrases. Having a vocabulary of only four words indicates a significant delay in speech and language development that should be reported to the provider.
Choice A is wrong because drawing a circle is a normal fine motor skill for a 24- month-old toddler.
Choice C is wrong because jumping with both feet is a normal gross motor skill for a 24-month-old toddler.
Choice D is wrong because weighing 12 kg (26.5 Ib) is within the average range for a 24-month-old toddler.