A 3-month-old with bronchiolitis is brought to the clinic experiencing irritability and poor oral intake. Which finding should alert the practical nurse (PN) that the child is in acute respiratory distress?

Flaring of the nares.

Resting respiratory rate of 35 breaths/minute.

Bilateral bronchial breath sounds.

Diaphragmatic respirations.

Answer and Explanation

The Correct Answer is A

Flaring of the nares, or widening of the nostrils, is a sign of respiratory distress in infants. It indicates that the child is working harder to breathe. This finding should alert the practical nurse (PN) that the child with bronchiolitis is in acute respiratory distress.

A resting respiratory rate of 35 breaths/minute (B) is within the normal range for a 3-month-old infant. Bilateral bronchial breath sounds (C) and diaphragmatic respirations (D) are not specific signs of acute respiratory distress in infants.

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Correct Answer is C

Explanation

Restlessness, confusion, and agitation are common symptoms of dementia, particularly in the evening, a phenomenon known as sundowning. Therefore, the PN should implement interventions that can help to prevent or minimize these symptoms. Assigning the client to a room close to the nurses' station can help to provide constant observation and reassurance and can help to prevent the client from wandering or becoming disoriented.
A. Delaying administration of nighttime medications until after visitors have left may be appropriate, but it is not the first intervention to be implemented in this scenario.
B. Administering a prescribed PRN benzodiazepine at the onset of a confused state may be appropriate in some cases, but it should not be the first intervention to be implemented in this scenario.
D. Asking family members about how they dealt with the client in the evening may be helpful, but it is not the first intervention to be implemented in this scenario.

A. The mother has changed 3 wet diapers. B. The infant has not emptied a 3 oz formula bottle. C. The infant has not passed meconium stool. D. The mother has used the bulb syringe.

Correct Answer is C

Explanation

Passage of meconium stool is a normal and expected event in the first 24-48 hours of life. The absence of meconium stool can be indicative of bowel obstruction or other underlying medical conditions, and requires further investigation and evaluation by the healthcare team. The other options are important pieces of information, but they do not carry the same level of urgency as the absence of meconium stool.

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A 3-month-old with bronchiolitis is brought to the clinic experiencing irritability and poor oral intake. Which finding should alert the practical nurse (PN) that the child is in acute respiratory distress?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The practical nurse (PN) notes that in the evening this client often becomes restless, confused, and agitated. Which intervention should the PN implement?

Correct Answer is C

Explanation

Which information is most important for the practical nurse (PN) to relay to the registered nurse (RN) concerning a 24-hour-old infant?

Correct Answer is C

Explanation

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