A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever, and cough for the last two days Which finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
A resting respiratory rate of 35 breaths/min.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
The Correct Answer is A
A) Correct - Flaring of the nares is a sign of increased respiratory effort and can indicate acute respiratory distress.
B) Incorrect - While a resting respiratory rate of 35 breaths/min is elevated for a 4-month-old infant, it may not necessarily indicate acute distress, especially when considered along with other signs.
C) Incorrect - Bilateral bronchial breath sounds may indicate lung pathology, but they are not specific to acute respiratory distress.
D) Incorrect - Diaphragmatic respirations, where the abdomen moves more than the chest during breathing, are normal for infants. They do not necessarily indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
They are needed to remove the saline lock safely and prevent bleeding or infection. The PN should wear exam gloves to protect themselves and the client from contamination, apply a small gauze pad over the insertion site, and secure it with paper tape after removing the saline lock.
Correct Answer is D
Explanation
A) Incorrect- While notifying the healthcare provider is an important step to take after an error, it's not the first action the nurse should take. The immediate concern is the client's safety and well-being, so assessing the client for any adverse effects of the incorrect dose is the priority.
B) Incorrect- Documentation is important, but it's not the first action to take after administering an incorrect medication dose. The nurse should prioritize assessing the client for any adverse effects and ensuring their immediate safety.
C) Incorrect- Completing an incident report is an important step to document errors and prevent future occurrences, but it's not the initial action to take. First, the nurse should focus on the client's well-being by assessing for adverse effects.
D) Correct- Assessing the client for any adverse effects is the immediate priority when an incorrect dose of medication has been administered. The nurse's first concern is the safety and health of the client. Once the client's condition has been assessed and stabilized, further actions can be taken, such as notifying the healthcare provider and completing incident reports.
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