Sabina Vasquez- VSim Complex Post-quiz-Questions
with Answers
Which assessment finding(s) would require nursing intervention? (Select all that apply.) - CORRECT
ANSWER-Temperature of 102.2°F (39°C),
Blood pressure 80/55 mmHg,
Respiratory rate 26 breaths/min,
Crackles in right lower lobe
Rationale: A temperature of 102.2° F (39°C) would indicate a fever and would require nursing
intervention. Right lower lobe crackles indicate impaired gas exchange and would require intervention. A
respiratory rate of 26 breaths/min is outside of the normal respiratory rate in a school-age child, which
ranges from 16 to 22 breaths/min, and would therefore require intervention. Similarly, a blood pressure
of 80/55 mmHg is outside the normal blood pressure values in a school-age child, which range from 95
to 120 mmHg systolic and 60 to 76 mmHg diastolic, so this finding would require intervention. An oxygen
saturation of 92% or greater would be considered normal. During the school-age years, the heart rate
ranges from 70 to 110 beats/min, so a heart rate of 84 beats/min is considered normal.
The nurse is concerned about Sabina's airway. Which assessment finding(s) would indicate the
development of respiratory failure? (Select all that apply.) - CORRECT ANSWER-Bradycardia, PaCO2 60
mmHg, Cyanosis
Rationale: Respiratory failure causes bradycardia, cyanosis, and hypotension. A PaCO2 greater than 50
mmHg indicates respiratory failure. Nasal flaring and hypertension are manifestations of respiratory
distress, not respiratory failure. A PaO2 greater than 60 mmHg indicates respiratory distress, not
respiratory failure.
The nurse notes mild __________ during the respiratory assessment, which makes the nurse suspect
that Sabina is experiencing __________________. - CORRECT ANSWER-intercostal retractions,
respiratory distress
Rationale: Intercostal retractions would be noted during the respiratory assessment. Temperature, white
blood cell count, and abdominal pain are not assessed during the respiratory assessment. Mild
intercostal retractions indicate respiratory distress. Respiratory failure would cause severe retractions,
not mild retractions. Hypovolemic shock and uncomplicated pneumonia would not cause retractions.
with Answers
Which assessment finding(s) would require nursing intervention? (Select all that apply.) - CORRECT
ANSWER-Temperature of 102.2°F (39°C),
Blood pressure 80/55 mmHg,
Respiratory rate 26 breaths/min,
Crackles in right lower lobe
Rationale: A temperature of 102.2° F (39°C) would indicate a fever and would require nursing
intervention. Right lower lobe crackles indicate impaired gas exchange and would require intervention. A
respiratory rate of 26 breaths/min is outside of the normal respiratory rate in a school-age child, which
ranges from 16 to 22 breaths/min, and would therefore require intervention. Similarly, a blood pressure
of 80/55 mmHg is outside the normal blood pressure values in a school-age child, which range from 95
to 120 mmHg systolic and 60 to 76 mmHg diastolic, so this finding would require intervention. An oxygen
saturation of 92% or greater would be considered normal. During the school-age years, the heart rate
ranges from 70 to 110 beats/min, so a heart rate of 84 beats/min is considered normal.
The nurse is concerned about Sabina's airway. Which assessment finding(s) would indicate the
development of respiratory failure? (Select all that apply.) - CORRECT ANSWER-Bradycardia, PaCO2 60
mmHg, Cyanosis
Rationale: Respiratory failure causes bradycardia, cyanosis, and hypotension. A PaCO2 greater than 50
mmHg indicates respiratory failure. Nasal flaring and hypertension are manifestations of respiratory
distress, not respiratory failure. A PaO2 greater than 60 mmHg indicates respiratory distress, not
respiratory failure.
The nurse notes mild __________ during the respiratory assessment, which makes the nurse suspect
that Sabina is experiencing __________________. - CORRECT ANSWER-intercostal retractions,
respiratory distress
Rationale: Intercostal retractions would be noted during the respiratory assessment. Temperature, white
blood cell count, and abdominal pain are not assessed during the respiratory assessment. Mild
intercostal retractions indicate respiratory distress. Respiratory failure would cause severe retractions,
not mild retractions. Hypovolemic shock and uncomplicated pneumonia would not cause retractions.
