A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status?
(Select All that Apply.)
Warm extremities
Wheezing
Nasal flaring
Retraction of sternal muscles
Oxygen saturation 95%
Correct Answer : B,C,D
B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.
C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.
D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.
A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.
E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. The correct action would be to place the client on NPO (Nothing by Mouth) status, option D. This is because a decreased level of consciousness can increase the risk of aspiration.
A. Liver biopsy is not indicated for suspected meningitis with a decreased level of consciousness. Liver biopsy is a procedure used to obtain a sample of liver tissue for diagnostic purposes, typically to evaluate liver function or diagnose liver diseases.
B. A protective environment (option B) is more related to immunocompromised patients. In the case of decreased level of consciousness, preventing aspiration is key.
C. Dorsal recumbent position refers to lying on the back with the knees flexed. While this position may be suitable for certain medical procedures or examinations, it is not specifically indicated for a client with suspected meningitis and a decreased level of consciousness.
Correct Answer is B
Explanation
B. The most serious complication associated with skeletal traction is osteomyelitis, an infection that involves the bone. This condition can occur when organisms gain access to the bone either systemically or through the openings created by the metal pins or wires used in the traction.
A. Increased blood pressure can occur for various reasons but it is not the most serious complication associated with skeletal traction.
C. A decrease in urine output could indicate systemic infection which is a late feature of osteomyelitis and therefore, not the earliest to monitor.
D. Changes in appetite can occur in response to pain or stress but they are not typically the most serious complication associated with skeletal traction.
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