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 D
Explanation
The correct answer is Choice D.
Choice A rationale
A low-carbohydrate, low-protein diet is not appropriate for a child with acute glomerulonephritis. Carbohydrates and proteins are essential nutrients, and restricting them can lead to malnutrition and other complications.
Choice B rationale
A regular diet with no added salt is not sufficient for managing acute glomerulonephritis with peripheral edema. Sodium restriction is necessary to help reduce fluid retention and edema.
Choice C rationale
A low-protein, low-potassium diet is not the best choice for managing acute glomerulonephritis. While protein and potassium intake may need to be monitored, the primary focus should be on sodium and fluid restriction.
Choice D rationale
A low-sodium, fluid-restricted diet is the correct choice. Sodium restriction helps reduce fluid retention and edema, while fluid restriction helps manage fluid balance and prevent further complications.
Correct Answer is ["B","D","E","F"]
Explanation
The correct answers are Choices B, D, E, and F.
Choice A rationale:
Administering promethazine 50 mg intermittent IV bolus is not typically indicated for managing acute abdominal pain and suspected appendicitis. Promethazine is an antiemetic and antihistamine, but it does not address the underlying cause of the symptoms.
Choice B rationale:
Obtaining informed consent for surgery is crucial as the client’s symptoms and lab results (elevated WBC count and C- Reactive Protein) strongly suggest appendicitis. Surgery, specifically an appendectomy, is the definitive treatment for appendicitis.
Choice C rationale:
Administering acetaminophen 800 mg may help alleviate pain and reduce fever, but it does not address the underlying cause of the symptoms. It is important to manage the pain, but the primary focus should be on diagnosing and treating the appendicitis.
Choice D rationale:
Initiating IV antibiotics is essential in managing suspected appendicitis to prevent infection and complications such as perforation or abscess formation. Antibiotics help control the infection until surgical intervention can be performed.
Choice E rationale:
Maintaining NPO (nothing by mouth) status is important to prepare the client for potential surgery and to prevent exacerbation of symptoms. Keeping the client NPO helps reduce the risk of aspiration during anesthesia and surgery.
Choice F rationale:
Obtaining an abdominal ultrasound is important to confirm the diagnosis of appendicitis. Imaging studies such as ultrasound or CT scan can help visualize the appendix and assess for inflammation or other abnormalities.
Choice G rationale:
Administering enemas until clear is not appropriate in this scenario. Enemas are not indicated for managing acute abdominal pain and suspected appendicitis. They could potentially worsen the condition or mask important symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.