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

Answer and Explanation

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.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: It is the nurse's responsibility to administer medication, not the caregiver's, to ensure proper dosage and method.

Choice B reason: Calculating the safe dosage is essential to avoid underdosing or overdosing, which can be harmful to the toddler's health.

Choice C reason: Offering juice after medication can help wash down the taste and ensure the medication is swallowed properly.

Choice D reason: Identifying the toddler by asking the caregiver ensures that the correct child receives the medication, which is a critical safety step.

Choice E reason: Asking the toddler to pick a toy can provide comfort and distraction, making the administration process smoother and less stressful for the child.

A. Empty the bladder completely with each void. B. Wear cotton underpants. C. Wipe the perineal area from front to back. D. Avoid bubble baths. E. Watch for manifestations of infection.

Correct Answer is ["B","C","D","E"]

Explanation

Choice A reason: It is important to empty the bladder completely to prevent urine from remaining in the bladder, which can promote bacterial growth. However, this choice is not specific to teaching and is a general practice for anyone.

Choice B reason: Wearing cotton underpants is recommended because cotton is breathable and reduces moisture buildup, which can create an environment conducive to bacterial growth. The normal range for breathability in fabrics is not quantifiable but is a qualitative characteristic.

Choice C reason: Wiping from front to back helps prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTI. This is a key teaching point for preventing UTI recurrence.

Choice D reason: Bubble baths can irritate the urethral opening and are associated with an increased risk of UTIs, especially in children. Avoiding them is a preventive measure that should be included in the teaching.

Choice E reason: Watching for manifestations of infection, such as fever, pain, or changes in urine, is crucial for early detection and treatment of UTIs. Parents should be taught to monitor these signs closely.

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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.)

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