NCLEX-PN

Explanation: The correct answer is (C) as delaying the assessment of distal pulses for two hours after a cardiac catheterization constitutes a breach of the standard of care, where prompt and frequent assessments are crucial to monitor for potential complications and ensure the client's safety. (A) and (D) are considered incorrect since providing warm water for hair combing, as described, is generally safe and aligns with standard care practices, while the nurse observing appropriate infection control practices does not represent negligence. Furthermore, (B) is not the correct choice, as negligence in medication administration would only apply if the nurse fails to follow the medication order correctly, leading to harm to the client. (See Malpractice ) 20. You measure your 5-year-old client’s vital signs as: ●​ Respiratory rate: 32 breaths per minute ●​ Pulse: 100 beats per minute ●​ Blood pressure: 85/55 The mother asks you if these vital signs are normal. You should respond to this mother by stating:

A.​ “The respiratory rate is a little too fast but the other vital signs are normal.” B.​ “The pulse rate is a little too fast but the other vital signs are normal.” C.​ “The blood pressure is a little low but the other vital signs are normal.” D.​ “All of these vital signs are normal for a child that is 5 years of age.” Correct Response: A

Explanation: The correct answer is (A) "The respiratory rate is a little too fast but the other vital signs are normal." For a 5-year-old, the normal respiratory rate should fall within the range of 22 to 30 breaths per minute, and in this case, the measured rate of 32 breaths per minute is slightly elevated. However, the pulse rate (100 beats per minute) and blood pressure (85/55) fall within the typical ranges for a preschool child. It's important to highlight that the elevated respiratory rate may indicate the need for further assessment or monitoring. The incorrect responses include (B) , as the pulse rate is within the normal range, (C) , as the blood pressure is also within the expected range for a 5-year-old, and (D) , which is inaccurate due to the elevated respiratory rate. Understanding and interpreting age-appropriate vital sign ranges are crucial for healthcare providers to effectively assess and address the health status of young children. (See Providing Care for Different Age Groups: Preschool to Middle Age Adults ) 21. The A, B. C, Ds of a complete and comprehensive nutritional assessment includes:

A.​ Assessment data, biochemical data, clinical data, and dietary data B.​ Ancestral cultural data, biochemical data, clinical data, and dietary data C.​ Anthropometric data, biological data, chemical data, and dietary data D.​ Anthropometric data, biochemical data, clinical data, and dietary data Correct Response: D

Explanation : The correct answer is (D) Anthropometric data, biochemical data, clinical data, and dietary data. A comprehensive nutritional assessment involves the evaluation of an individual's nutritional status through four key components represented by the A, B, C, and D. A encompasses Anthropometric Data, including physical measurements like height, weight, body mass index, and other body

628

© 2025 ACHIEVE ULTIMATE CREDIT-BY-EXAM GUIDE | NCLEX-PN ​

​

​

​

​