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 B

Explanation

A. Enrolling the UAP in a hospital education class on conducting safe client care is unnecessary at this moment. The immediate concern is ensuring the client's safety during the procedure.

B. Stopping the procedure and instructing the UAP to place the client in Fowler's position (or at least semi-Fowler's) is the correct action. This position helps prevent aspiration during oral hygiene for an unconscious client.

C. Praising the UAP for performing oral hygiene does not address the safety risk present in this situation. While family participation is encouraged, it should not be the focus here.

D. Telling the UAP to continue because the unconscious client is positioned safely is incorrect, as the flat side-lying position increases the risk of aspiration. Ensuring the client is positioned properly is essential for their safety.

A. Provide a regular diet tray B. Measure vital signs C. Apply oxygen 1 L/min D. Give Albuterol as ordered E. Perform pulmonary function test

Correct Answer is ["B","D"]

Explanation

A) Incorrect - Providing a regular diet tray is important for the client's nutritional needs, but it is not as urgent as assessing vital signs or administering Albuterol in response to the client's acute symptoms.
B) Correct- This action is a priority after any assessment or intervention. Vital signs provide important information about the client's overall condition, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
C) Incorrect - Applying oxygen is important, but its priority depends on the client's vital signs and oxygen saturation, which should be assessed first.
D) Correct- Administering Albuterol as ordered is crucial for addressing the client's acute breathing difficulty. Albuterol is a bronchodilator that helps alleviate asthma symptoms, and timely administration is essential.
E) Incorrect - Performing a pulmonary function test is valuable for assessing lung function, but it's not an immediate concern compared to addressing the client's breathing difficulty.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

Correct Answer is B

Explanation

Find patient data about a client below. After the nurse assesses the client, the physician writes orders. The nurse reviews the orders. Which 2 orders should the nurse complete first?

Correct Answer is ["B","D"]

Explanation

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