A 1-year-old child with respiratory syncytial virus (RSV) has been admitted to the pediatric unit. The nurse observes that the child has a fever, rhinorrhea, frequent coughing, and sneezing.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
A resting respiratory rate of 35 breaths/min.
The Correct Answer is A
Flaring of the nares is a sign of increased respiratory effort, which is a manifestation of acute respiratory distress. This finding occurs when the child is attempting to draw in more air to meet the increased demand for oxygen.
Bilateral bronchial breath sounds can indicate consolidation or a bronchial obstruction, but they are not specific to acute respiratory distress.
Diaphragmatic respirations are a normal finding and may occur in response to respiratory distress, but they do not necessarily indicate acute respiratory distress.
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and does not necessarily indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
During the initial phase of treatment for osteomyelitis, the nurse should instruct the child and parent to ensure that there is no weight bearing on the affected extremity. This may require the use of assistive devices such as crutches or a wheelchair. Administering topical antibiotic therapy, providing passive range of motion exercises, and scheduling ice pack applications to the infected area are not appropriate interventions during the initial phase of treatment.
Topical antibiotics may be used later in the course of treatment, after the initial phase of intravenous antibiotics has been completed.
Passive range of motion exercises may be appropriate during the later phases of treatment to prevent joint contractures.
Ice pack applications may be appropriate for pain relief, but they are not a primary intervention for osteomyelitis.
Correct Answer is B
Explanation
When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the affected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.
Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.
Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.
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