A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

Nasal flaring present.

Suprasternal retractions present.

Intercostal retractions present.

Subcostal retractions present.

Answer and Explanation

The Correct Answer is C

A. Nasal flaring present. Nasal flaring is a separate sign of respiratory distress, but it does not describe retractions.

B. Suprasternal retractions present. Suprasternal retractions occur above the sternum, not between the ribs.

C. Intercostal retractions present. Intercostal retractions occur between the ribs and indicate difficulty breathing due to increased respiratory effort.

D. Subcostal retractions present. Subcostal retractions occur below the ribcage, not between the ribs.

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Correct Answer is B

Explanation

A. Move body parts rapidly through the movements. Passive range of motion (ROM) should be performed slowly and gently to prevent injury or pain.

B. Support extremities above and below joints. Supporting both above and below the joint helps prevent excessive strain and allows for controlled movement.

C. Continue moving body parts if muscle spasticity occurs. If muscle spasticity occurs, the nurse should stop and reassess before continuing, to avoid injuring the client.

D. Stretch the body part just beyond the existing range of motion. The nurse should never push beyond the client’s normal range, as this can cause pain or injury.

A. Having the client perform range-of-motion exercises of the arm B. Inspecting the site for reduced swelling C. Asking the client to rate the pain D. Monitoring the client's pulse rate

Correct Answer is C

Explanation

A. Having the client perform range-of-motion exercises of the arm. While movement may improve after treatment, this is not a direct measure of the effectiveness of a cold compress.

B. Inspecting the site for reduced swelling. Cold therapy reduces swelling by vasoconstriction. Swelling reduction can be an indicator of decreased inflammation but it does not provide a direct assessment of the client’s pain levels.

C. Asking the client to rate the pain. This is the most direct and reliable method to determine the effectiveness of a cold compress for pain relief.

D. Monitoring the client's pulse rate. Cold therapy does not significantly affect systemic circulation to the extent that it impacts pulse rate.

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A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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