A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply.)
Oxygen saturation 95%
Warm extremities
Wheezing
Nasal flaring
Retraction of sternal muscles
Correct Answer : C,D,E
Choice A reason: An oxygen saturation of 95% is within the normal range and does not indicate respiratory deterioration.
Choice B reason: Warm extremities are not an indication of respiratory status deterioration; they are generally a sign of good circulation.
Choice C reason: Wheezing is a common sign of airway obstruction in asthma and can indicate a deterioration in respiratory status.
Choice D reason: Nasal flaring is a sign of increased work of breathing and can indicate respiratory distress in a child with asthma.
Choice E reason: Retraction of sternal muscles is a sign of respiratory distress and can indicate a worsening condition in a child with asthma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A reason: Using a universal dropper ensures accurate dosing, which is crucial for infants due to their small size and the precise dosing required for their medications.
Choice B reason: Adding medication to a formula bottle is not recommended because if the infant does not finish the bottle, they will not receive the full medication dose.
Choice C reason: Flavoring can help mask the taste of medications, making it easier for infants to take them, which is especially useful if the medication has an unpleasant taste.
Choice D reason: Using the nipple of a bottle can be an effective way to administer medication to an infant who is used to bottle-feeding, as it can make the process more familiar and comfortable.
Correct Answer is B
Explanation
Choice A reason: While the Fowler's position can aid in breathing, it is not the first action to take if the oxygen saturation monitor is reading low.
Choice B reason: Ensuring the proper placement of the sensor probe is the first step, as incorrect placement can lead to inaccurate readings.
Choice C reason: Increasing the oxygen flow rate should only be considered after confirming the accuracy of the oxygen saturation reading.
Choice D reason: Encouraging deep breaths may be helpful, but it is not the first action to take. The priority is to ensure the oxygen saturation reading is accurate.
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