A nurse is caring for a 2-year-old male toddler in the emergency department.
Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)
Nasal flaring
Retractions
Oxygen saturation
Breath sounds in bilateral bases
Respiratory rate
Heart rate
Correct Answer : C,D,E
Choice A rationale:
Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.
Choice B rationale:
Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.
Choice C rationale:
Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 89% on room air to higher levels) indicates that the treatment plan is effective in improving the child’s oxygenation.
Choice D rationale:
Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of clear breath sounds or reduced wheezing indicates improvement in the child’s respiratory status.
Choice E rationale:
Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 42 breaths/min to a lower rate) indicates that the treatment plan is effective in reducing the child’s respiratory distress.
Choice F rationale:
Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Turning the child’s head to the side and pressing on the nasal ridge is not the recommended method for managing nosebleeds. This position can cause blood to flow into the throat, leading to swallowing blood and potential vomiting.
Choice B rationale
Sitting the child upright and leaning slightly forward while applying pressure to the sides of the nose is the correct method. This position helps prevent blood from flowing into the throat and allows it to clot more effectively.
Choice C rationale
Having the child lie flat and apply pressure to the cheeks is not effective for stopping a nosebleed. This position can cause blood to flow into the throat, leading to swallowing blood and potential vomiting.
Choice D rationale
Putting the child in bed, elevating the head slightly, and pressing on the forehead is not effective for stopping a nosebleed. The pressure needs to be applied directly to the soft part of the nose to control the bleeding.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Talking to the baby each day at a special time can help build a bond and promote language development. However, it is not the most important factor in promoting the infant’s development of trust. Consistent and responsive caregiving is more crucial in building trust.
Choice B rationale
Having many caregivers caring for the baby can lead to inconsistency in caregiving. According to Erikson’s theory of psychosocial development, infants need consistent and reliable caregiving to develop a sense of trust. Multiple caregivers can create confusion and insecurity for the baby.
Choice C rationale
Stimulating the baby with many toys can promote cognitive and motor development. However, it is not the most important factor in promoting the infant’s development of trust. Consistent and responsive caregiving is more crucial in building trust.
Choice D rationale
Responding to the baby’s needs consistently is the most important factor in promoting the infant’s development of trust. According to Erikson’s theory, infants develop trust when their caregivers are reliable and responsive to their needs. This consistent caregiving helps the baby feel secure and builds a foundation for healthy emotional development. .
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