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 should indicate to the nurse that the treatment is effective?
Barking cough
Decreased stridor
Decreased temperature
Improved hydration
The Correct Answer is B
Choice A reason: Barking cough is not a finding that indicates the effectiveness of the treatment. Barking cough is a sign of inflammation of the larynx and trachea, which causes a hoarse and harsh sound. It is a common symptom of acute laryngotracheobronchitis, also known as croup.
Choice B reason: Decreased stridor is a finding that indicates the effectiveness of the treatment. Stridor is a high-pitched, wheezing sound that occurs when the airway is narrowed or obstructed. It is a sign of respiratory distress and hypoxia. The cool mist tent helps to humidify and soothe the airway, reducing the swelling and inflammation.
Choice C reason: Decreased temperature is not a finding that indicates the effectiveness of the treatment. Decreased temperature could be a sign of hypothermia or sepsis, which are serious complications that require immediate attention. The normal temperature range for a toddler is 36.5°C to 37.5°C (97.7°F to 99.5°F).
Choice D reason: Improved hydration is not a finding that indicates the effectiveness of the treatment. Improved hydration is a sign of adequate fluid intake and output, which are important for maintaining electrolyte balance and preventing dehydration. However, hydration status does not directly affect the airway inflammation or obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Half-strength infant formula is not a clear liquid and should not be given to an infant with intussusception. Infant formula contains proteins, fats, and carbohydrates that can increase the risk of bowel obstruction, infection, and perforation.
Choice B reason: Half-strength orange juice is not a clear liquid and should not be given to an infant with intussusception. Orange juice contains fructose, citric acid, and potassium that can irritate the bowel, cause osmotic diarrhea, and worsen dehydration.
Choice C reason: Sterile water is a clear liquid, but it is not the best choice for an infant with intussusception. Sterile water does not contain any electrolytes or glucose and can dilute the blood sodium level, leading to hyponatremia and seizures.
Choice D reason: Oral electrolyte solution is the best fluid for an infant with intussusception, as it contains the optimal balance of electrolytes and glucose to prevent dehydration and restore fluid balance. Oral electrolyte solution is recommended by the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) for the management of dehydration in children.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as giving an oral rehydration solution to an infant who is projectile vomiting may worsen the dehydration and electrolyte imbalance. The nurse should advise the parent to stop feeding the infant and seek medical attention.
Choice B reason: This statement is incorrect, as burping the baby more frequently during feedings may not prevent the projectile vomiting, which is caused by a mechanical obstruction of the stomach, not by air swallowing. The nurse should assess the parent for signs of pyloric stenosis, such as a palpable olive-shaped mass in the right upper quadrant of the abdomen.
Choice C reason: This statement is correct, as bringing the baby in to the clinic today is the best course of action for an infant who is projectile vomiting, which is a sign of a serious condition such as pyloric stenosis, a narrowing of the opening between the stomach and the small intestine. The nurse should inform the parent that the infant needs immediate evaluation and treatment to prevent complications such as dehydration, malnutrition, and metabolic alkalosis.
Choice D reason: This statement is incorrect, as trying switching to a different formula may not help the infant who is projectile vomiting, which is not related to the type of formula, but to a structural problem in the gastrointestinal tract. The nurse should not suggest changing the formula without consulting the provider.
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