A nurse in a provider's office is caring for a child who has a history of asthma. Which of the following findings should the nurse report to the provider?
Respiratory rate of 24 breaths/min
Wheezes in the lower lobes
Oxygen saturation of 95%
Peak expiratory flow rate of 80% of personal best
The Correct Answer is B
Choice A reason: A respiratory rate of 24 breaths/min is within the normal range for a child, depending on their age. It does not indicate respiratory distress or asthma exacerbation.
Choice B reason: Wheezes in the lower lobes are a sign of airway obstruction and inflammation due to asthma. They indicate that the child may need additional medication or intervention to relieve their symptoms. The nurse should report this finding to the provider.
Choice C reason: An oxygen saturation of 95% is within the normal range for a child. It does not indicate hypoxia or impaired gas exchange due to asthma.
Choice D reason: A peak expiratory flow rate of 80% of personal best is considered a green zone result, meaning that the child's asthma is well controlled. It does not indicate a need for change in the child's asthma action plan.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A 2-year-old toddler is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 2-year-old toddler may receive the meningococcal polysaccharide (MPSV4) vaccine instead, if indicated.
Choice B reason: A 4-month-old infant is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 4-month-old infant may receive the meningococcal serogroup B (MenB) vaccine instead, if indicated.
Choice C reason: An 11-year-old school-age child is a recommended recipient of the MCV4 vaccine, as it is routinely given to children aged 11 to 12 years old, with a booster dose at age 16. The MCV4 vaccine protects against four types of meningococcal bacteria (A, C, W, and Y) that can cause serious infections of the lining of the brain and spinal cord (meningitis) or the bloodstream (septicemia).
Choice D reason: A 4-year-old child is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 4-year-old child may receive the meningococcal polysaccharide (MPSV4) vaccine instead, if indicated.
Correct Answer is B
Explanation
Choice A reason: Placing the client in a private room is not necessary for a client who has a high WBC count, unless they have other indications for isolation, such as an infectious disease. A high WBC count may indicate inflammation, infection, or other conditions that affect the immune system.
Choice B reason: Monitoring the client's temperature every 4 hr is an appropriate action for a nurse to take for a client who has a high WBC count. A fever is a common sign of infection or inflammation, and it may require further intervention, such as antibiotics or antipyretics.
Choice C reason: Administering an antihistamine as prescribed is not related to a high WBC count. Antihistamines are used to treat allergic reactions, which may cause a low WBC count due to the release of histamine from mast cells.
Choice D reason: Encouraging the client to increase fluid intake is not specific to a high WBC count. Fluid intake should be based on the client's hydration status, urine output, and other factors. Increasing fluid intake may help flush out toxins or bacteria, but it is not a priority action for a client who has a high WBC count.
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