A nurse is caring for a child with croup in the hospital.
The child is receiving humidified air and nebulized racemic epinephrine.
The nurse monitors the child's respiratory status closely.
Which of the following findings would indicate to the nurse that the child's condition is worsening?
The child's oxygen saturation is 95%.
The child's respiratory rate is 30 breaths per minute.
The child has mild retractions.
The child is able to speak in complete sentences.
The Correct Answer is B
Choice A rationale:
An oxygen saturation level of 95% is within the normal range (normal range is typically 95-100%).
While it is essential to monitor oxygen saturation, this value does not indicate worsening of the child's condition.
Choice B rationale:
A respiratory rate of 30 breaths per minute is above the normal range for a child and can indicate respiratory distress.
An increased respiratory rate is a concerning sign, suggesting the child is having difficulty breathing.
This finding indicates the child's condition is worsening and requires prompt attention.
Choice C rationale:
Mild retractions suggest that the child is working harder to breathe but may not necessarily indicate a severe worsening of the condition.
Retractions are a sign of increased respiratory effort but may vary in severity.
Choice D rationale:
A child with croup experiencing severe respiratory distress may not be able to speak in complete sentences due to the difficulty in breathing.
However, the ability to speak in complete sentences alone may not be a definitive indicator of worsening.
Monitoring the respiratory rate and effort is crucial in assessing the child's condition accurately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Administering oxygen therapy is essential in cases of severe croup where the child has difficulty breathing.
Oxygen therapy helps ensure adequate oxygenation, which is crucial in managing respiratory distress.
Choice B rationale:
Positioning the child upright facilitates breathing by allowing the airways to remain open and reducing airway obstruction.
This position helps alleviate symptoms like stridor and allows the child to breathe more comfortably.
Choice C rationale:
Providing humidified air helps loosen secretions and makes it easier for the child to breathe.
Humidification can reduce airway irritation and soothe the inflamed throat, providing relief from croup symptoms.
Choice D rationale:
This choice is incorrect because encouraging the child to drink plenty of fluids is generally good advice for any illness but is not specific to croup.
While it is essential to keep the child hydrated, it is not a direct nursing intervention for managing croup symptoms.
Choice E rationale:
Monitoring the child's respiratory status closely is crucial in assessing the effectiveness of the interventions and identifying any signs of respiratory distress.
Close monitoring allows nurses to make timely decisions and take appropriate actions to maintain the child's respiratory function.
Correct Answer is ["A","D"]
Explanation
Choice A rationale:
There is no vaccine to prevent croup, but practicing good hand hygiene and avoiding contact with sick people can help reduce the child's risk of getting croup.
Croup is mainly caused by viral infections, so minimizing exposure to viruses is essential in prevention.
Choice B rationale:
Giving a daily dose of vitamin C is not a proven method for preventing croup.
While vitamin C is essential for overall health, it does not specifically prevent croup.
Providing accurate and evidence-based information is crucial in parental education.
Choice C rationale:
Keeping the child's bedroom cool and humid may provide comfort during the illness, but it is not a proven method for preventing croup.
This statement does not contribute significantly to preventive measures against croup.
Choice D rationale:
Using a humidifier in the home can help maintain adequate humidity levels, which may reduce the risk of croup, especially during dry seasons.
Proper humidity can prevent irritation of the upper respiratory tract and decrease the likelihood of developing croup.
Including this information in the teaching is appropriate and beneficial for the parent to know.
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