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 C
Explanation
Choice A reason: Collecting a stool specimen for culture is not the preferred method for diagnosing Enterobius vermicularis, as the pinworm eggs are rarely present in the stool.
Choice B reason: Initiating IV fluids is not a diagnostic measure for Enterobius vermicularis and is not relevant unless the child is dehydrated or requires fluids for another reason.
Choice C reason: The tape test is the standard diagnostic procedure for Enterobius vermicularis. It involves placing clear tape around the anus to collect any eggs that may be present, which are then examined under a microscope.
Choice D reason: Testing the stool for occult blood is not a diagnostic measure for Enterobius vermicularis, as this infection does not typically cause bleeding.
Correct Answer is A
Explanation
Choice A reason: The anterolateral thigh is the recommended site for intramuscular injections in toddlers due to the well-developed muscles and minimal risk of injury to nerves or blood vessels.
Choice B reason: Dividing the medication into two injections may be necessary for large volumes, but influenza vaccines typically do not require this.
Choice C reason: A 22-25 gauge needle is recommended for intramuscular injections in toddlers to minimize discomfort and tissue damage.
Choice D reason: While the supine position is not incorrect, a comfortable sitting position is preferable for toddlers to reduce anxiety and ensure a smooth vaccination process.
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