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
Explanation
Choice A reason: Enuresis can lead to emotional problems such as embarrassment, frustration, and low self-esteem, especially if not managed with sensitivity and support.
Choice B reason: While urinary tract infections can cause enuresis, they are not typically a complication of enuresis itself.
Choice C reason: Urosepsis is a severe infection that can result from a urinary tract infection but is not a common complication of enuresis.
Choice D reason: Progressive kidney disease is not a complication of enuresis. Enuresis is a symptom that can occur in various conditions, including kidney disease, but it does not cause the disease to progress.
Correct Answer is A
Explanation
Choice A reason: A blood creatinine level of 1.3 mg/dL is elevated for a school-age child and indicates impaired kidney function, which is a concern in acute glomerulonephritis.
Choice B reason: A urine output of 550 mL in 24 hours is within the normal range for a school-age child and does not need to be reported unless there is a significant change.
Choice C reason: A blood pressure of 100/74 mm Hg is within the normal range for a school-age child and does not indicate an immediate concern.
Choice D reason: A BUN level of 8 mg/dL is within the normal range for a school-age child and does not need to be reported unless there is a significant change.
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