A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?
A resting respiratory rate of 35 breaths/minute.
Flaring of the nares.
Diaphragmatic respirations.
Bilateral bronchial breath sounds.
The Correct Answer is B
A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.
B. Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.
C. Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.
D. Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
A. This describes a normal spine alignment.
B. This describes kyphosis, not lordosis.
C. Lordosis is an excessive inward curvature of the lumbar spine, often called "swayback."
D. This describes scoliosis, not lordosis.
Correct Answer is A
Explanation
A. A code blue indicates a life-threatening emergency. The nurse's primary responsibility is to attend to the collapsing client immediately. The PICC removal can be completed later.
B. Calling for an assistant allows the nurse to ensure the PICC removal is completed safely while also responding to the emergency situation.
C. Finishing the procedure would delay the response to the code, potentially compromising the care of the client experiencing the emergency.
D. Closing the room door is not relevant to managing either situation safely.
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