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 A

Explanation

This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the ﬂowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.

The other options are not correct because:

B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.

C. The supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not aﬀect the oxygen delivery or uptake.

D. The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen ﬂow or diﬀusion.

A. Enroll the UAP in a hospital education class on conducting safe client care. B. Stop the procedure and tell the UAP to place the client in Fowler's position. C. Praise the UAP for doing the oral hygiene but encourage family participation. D. Tell the UAP to continue because the unconscious client is positioned safely. E. None F. None

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.

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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) is completing a focused assessment on a client who is prescribed oxygen at 3 liters per minute by nasal cannula. Which assessment finding by the PN requires immediate action?

Correct Answer is A

Explanation

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

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