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A nurse is caring for a child who is having difficulty breathing due to an asthma exacerbation. Which of the following areas should the nurse determine if the child is experiencing subcostal retractions? (You will find hot spots to select in the artwork below. Select only the hot corresponds to your answer.)

Answer and Explanation

The Correct Answer is "{\"xRanges\":[232.4270782470703,272.4270782470703],\"yRanges\":[382.1666450500488,422.1666450500488]}"

To determine if the child is experiencing subcostal retractions, check the area beneath the ribcage.

D - Subcostal Area:

Subcostal retractions occur below the ribs and are a sign of respiratory distress, indicating increased effort to breathe.

Observing this area can reveal inward movement during inspiration, suggesting difficulty in breathing, often seen in asthma exacerbations.

Rationale

A - Incorrect:

This area is near the clavicle and not related to subcostal retractions.

B - Incorrect:

This is the intercostal area, which can also show retractions but is not subcostal.

C - Incorrect:

This area is too central and does not correspond with subcostal retractions.

Focusing on D allows the nurse to assess the presence of subcostal retractions effectively.

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Correct Answer is D

Explanation

A) Double-bag the client's trash before removing it from the room: While double-bagging is a precaution used in certain infections to prevent contamination, it is not necessary for influenza. Influenza spreads via respiratory droplets rather than contact with contaminated objects. Standard waste disposal methods are typically sufficient to manage the risk of contamination from trash.

B) Place the client in a negative air pressure room with 6 to 12 air exchanges per hour: Negative air pressure rooms are designed to contain airborne pathogens by preventing contaminated air from escaping the room. Diseases such as tuberculosis or measles require this level of isolation. However, influenza spreads through droplets that settle quickly rather than remaining airborne, making negative air pressure rooms unnecessary for influenza isolation.

C) Ensure all air in the client's room is filtered through a HEPA filter: HEPA (High-Efficiency Particulate Air) filters are used to trap airborne particles. For influenza, which is spread by larger respiratory droplets, such filtration is not needed. The droplets are too large to remain suspended in the air and are typically spread through close contact, rather than requiring air filtration.

D) Wear a surgical mask when within 1 m (3 ft) of the client: This is the most appropriate precaution. Influenza is primarily spread through respiratory droplets that can travel about 1 meter (3 feet) when a person coughs, sneezes, or talks. Wearing a surgical mask within this distance helps prevent inhaling these droplets, thus reducing the risk of transmission. This aligns with droplet precautions which are standard for managing influenza.

A. Drink 8 oz of milk when hypoglycemia develops. B. Initiate a 1,400-calorie diet daily. C. Rotate the insulin injection site to a different area of the body with every other injection. D. Keep unopened insulin refrigerated at 4.44° C (40° F).

Correct Answer is D

Explanation

A) Drink 8 oz of milk when hypoglycemia develops:
While consuming a fast-acting carbohydrate is important during hypoglycemia, 8 oz of milk may not be the most effective choice. Typically, glucose tablets or juice are recommended as they provide a quicker absorption of sugar into the bloodstream.

B) Initiate a 1,400-calorie diet daily:
Caloric needs should be individualized based on the adolescent’s age, weight, activity level, and overall health. A fixed 1,400-calorie diet might not be appropriate for every adolescent and could lead to insufficient energy intake or excessive restriction.

C) Rotate the insulin injection site to a different area of the body with every other injection:
While rotating injection sites is important to prevent lipodystrophy, it is generally recommended to use different sites within the same area (such as different spots on the abdomen) rather than entirely different areas of the body with each injection. This ensures consistent absorption of insulin.

D) Keep unopened insulin refrigerated at 4.44° C (40° F):
Unopened insulin should be stored in the refrigerator to maintain its potency until it is ready to be used. This temperature range ensures the insulin remains stable and effective for use.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has the communicable disease influenza. Which of the following isolation precautions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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