A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings indicates that the treatment has been effective?
Decreased stridor
Improved hydration
Decreased temperature
Barking cough
The Correct Answer is A
Choice A reason:
Decreased stridor: Stridor is a high-pitched, wheezing sound caused by disrupted airflow. In acute laryngotracheobronchitis (croup), stridor is a common symptom due to inflammation and narrowing of the airways. The effectiveness of treatment, such as a cool mist tent, is often indicated by a reduction in stridor, as it suggests that the airway inflammation is decreasing and the airflow is improving.
Choice B reason:
Improved hydration: While maintaining hydration is important in managing croup, it is not a direct indicator of the effectiveness of the cool mist tent treatment. Improved hydration can be achieved through various means, such as oral fluids or intravenous therapy, and does not specifically reflect the reduction of airway inflammation.
Choice C reason:
Decreased temperature: Fever can be a symptom of croup, but a decrease in temperature is not a primary indicator of the effectiveness of the cool mist tent treatment. The main goal of the cool mist tent is to reduce airway inflammation and improve breathing, rather than to control fever.
Choice D reason:
Barking cough: A barking cough is a characteristic symptom of croup. While the cool mist tent can help soothe the airways and reduce coughing, the presence or absence of a barking cough alone is not a definitive indicator of treatment effectiveness. The primary focus is on reducing airway obstruction and improving airflow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5.6"]
Explanation
Calculation Steps
Step 1: Convert the toddler’s weight from pounds to kilograms.
- 33 lbs ÷ 2.2 = 15 kg
- Result: 15 kg
Step 2: Calculate the total daily dose of amoxicillin.
- 30 mg/kg/day × 15 kg = 450 mg/day
- Result: 450 mg/day
Step 3: Since the dose is divided equally every 12 hours, calculate the dose per administration.
- 450 mg/day ÷ 2 = 225 mg/dose
- Result: 225 mg/dose
Step 4: Determine the volume of the suspension to administer per dose.
- 225 mg ÷ (200 mg ÷ 5 mL) = 225 mg ÷ 40 mg/mL = 5.625 mL
- Result: 5.625 mL
Step 5: Round to the nearest tenth.
- 5.625 mL rounds to 5.6 mL
- Result: 5.6 mL
Therefore, the nurse should administer 5.6 mL of amoxicillin per dose.
Correct Answer is C
Explanation
Choice A: Places the infant in a side-lying position
Placing an infant with myelomeningocele in a side-lying position can help prevent pressure on the sac, but it is not the most critical action to indicate effective teaching. The primary concern is to protect the sac from infection and injury, which is best achieved by maintaining a dry dressing over it.
Choice B: Performs range of motion on the infant’s hips
Performing range of motion exercises on the infant’s hips is important for preventing joint contractures and promoting mobility. However, this action does not directly address the immediate need to protect the sac from infection and injury, which is the most critical aspect of care for an infant with myelomeningocele.
Choice C: Maintains a dry dressing over the sac
Maintaining a dry dressing over the sac is crucial for preventing infection and protecting the exposed spinal cord and nerves. This action directly addresses the primary concern in the care of an infant with myelomeningocele, which is to prevent infection and further injury to the exposed neural tissue. Therefore, this choice indicates that the new nurse has effectively understood the most critical aspect of care for these infants.
Choice D: Takes an axillary temperature
Taking an axillary temperature is a standard nursing procedure for monitoring an infant’s temperature. While it is important, it does not specifically address the unique needs of an infant with myelomeningocele. The primary concern remains the protection of the sac, making this action less indicative of effective teaching in this context.
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