A nurse is caring for a 2-year-old toddler in the pediatric unit who was admitted from the emergency department due to concerns about the child’s breathing.
Which of the following findings should the nurse on the pediatric unit identify as an indication that the treatment plan is effective? (Select all that apply)
Nasal flaring
Retractions
Oxygen saturation
Respiratory rate
Pulse
Breath sounds in bilateral bases
Heart rate
Correct Answer : C,D,F
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 88% on room air to 94% on 2 L/min O2) indicates that the treatment plan is effective in improving the child’s oxygenation.
Choice D rationale:
Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 40 breaths/min to 32 breaths/min) indicates that the treatment plan is effective in reducing the child’s respiratory distress.
Choice E rationale:
Pulse rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in pulse rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.
Choice F rationale:
Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of mild bilateral expiratory wheezes and diminished breath sounds in the bases indicates some improvement compared to the initial assessment.
Choice G 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 A
Explanation
The correct answer is Choice A.
Choice A rationale
Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. It is crucial not to palpate the abdomen of a child with a suspected Wilms tumor because this can cause the tumor to rupture and spread cancerous cells to other parts of the body.
Choice B rationale
This choice is incorrect because there is no specific restriction on venipuncture or blood pressure measurements in the left arm for children with Wilms tumor. This precaution is typically associated with conditions like lymphedema or after a mastectomy.
Choice C rationale
Collecting all urine is not a specific precaution for Wilms tumor. While monitoring urine output can be important in various conditions, it is not a primary concern for Wilms tumor.
Choice D rationale
Contact precautions are not necessary for Wilms tumor as it is not an infectious disease. Contact precautions are typically used for conditions that are contagious or spread through direct contact.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Failure to thrive is a condition where a child does not gain weight or grow as expected. While severe diarrhea can contribute to failure to thrive, the immediate concern in this scenario is the significant weight loss indicating severe dehydration.
Choice B rationale
Malabsorption syndrome involves the inability to absorb nutrients properly, leading to malnutrition and weight loss. However, the acute weight loss in this case is more indicative of severe dehydration.
Choice C rationale
Severe dehydration is characterized by significant fluid loss, which can be life-threatening in infants. The weight loss from 11 pounds to 9 pounds, 8 ounces indicates a substantial fluid loss, pointing to severe dehydration.
Choice D rationale
Risk for fluid volume deficit is a potential diagnosis, but the significant weight loss and clinical presentation indicate that the infant is already experiencing severe dehydration.
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