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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Prior to inspecting the abdomen. The correct order of abdominal assessment is inspection → auscultation → percussion → palpation to avoid altering bowel sounds.
B. After checking for kidney tenderness. Assessing kidney tenderness is done through percussion, which should be performed after auscultation.
C. After palpating the abdomen. Palpation can stimulate bowel activity, potentially leading to false findings during auscultation.
D. Prior to palpating the abdomen. Auscultation should be done before palpation to prevent artificially altering bowel sounds.
Correct Answer is A
Explanation
A. Ask the client to push her legs and feet against the nurse's palms. This action directly assesses the client’s muscle strength and ability to bear weight, which is essential before ambulation.
B. Check the client's pedal pulses and feet for edema. While circulatory assessment is important, it does not assess muscle strength, which is needed for safe ambulation.
C. Ask the client if she has been out of bed today. The client’s response does not objectively measure strength or readiness for ambulation.
D. Ask the client how strong she feels today. A client’s perception of strength may not be accurate and is not an objective way to assess readiness for ambulation.
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