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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A: A double turn or square knot is not recommended because it is not a quick-release knot, which is necessary for patient safety in case of an emergency

Choice B: While restraints need to be secure, they should not be snug against the client's wrists. There should be enough space to fit two fingers between the restraint and the wrist to prevent circulation issues.

Choice C: Ties should not be secured to side rails as this can cause injury if the rails are moved. Instead, they should be attached to the movable part of the bed frame.

Choice D: This is the correct action. A half-bow knot is a type of quick-release knot, which is essential for the safety and quick release of the patient if needed

A. Palpate the rate and volume of the pulse. B. Check fingernails for the presence of clubbing. C. Measure body weight at the same time daily D. Observe the color and amount of urine E. Compare muscle strength of both arms.

Correct Answer is ["A","C","D"]

Explanation

The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of ﬂuid volume excess. These actions can help detect changes in the cardiovascular, renal, and ﬂuid balance systems that may indicate ﬂuid overload, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.

The other options are not correct because:

b. Checking fingernails for the presence of clubbing is not relevant for assessing ﬂuid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.

e. Comparing muscle strength of both arms is not relevant for assessing ﬂuid volume excess, as muscle weakness is not a specific sign of ﬂuid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.

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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?

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Naxlex Comprehensive Predictor Exams

Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Correct Answer is D

Explanation

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a client's room and find the client lying on the bed. The PN determines that the client is unresponsive. Which instruction should the PN give the UAP first?

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?