A nurse is taking vital signs on an infant diagnosed with bronchiolitis. Which of the following findings should the nurse immediately report to the provider?
Heart rate of 152 beats per minute
Temperature of 99.5°F (37.5°C)
Respiratory rate of 74 breaths per
Blood pressure of 90/60 mmHg
The Correct Answer is C
A. An elevated heart rate can be expected in infants with bronchiolitis due to increased work of breathing.
B. A slight elevation in temperature may be indicative of infection but is not an immediate concern.
C. A respiratory rate of 74 breaths per minute may indicate respiratory distress and warrants immediate attention.
D. A blood pressure of 90/60 mmHg is within the normal range for infants and not immediately concerning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Giving pancreatic enzymes before snacks and meals helps improve digestion and absorption of nutrients in children with CF.
B. Restricting salt intake is not typically necessary in CF; in fact, salt supplementation may be required, especially during hot weather or during episodes of increased sweating.
C. Limiting fluid intake is not typically necessary in CF; adequate hydration is important to maintain mucus clearance.
D. Children with CF often require a high-calorie, high-protein diet to meet their nutritional needs and support growth and weight gain.
Correct Answer is D
Explanation
A. Capillary refill assesses peripheral perfusion and is not directly related to tracheostomy suctioning.
B. Increased respiratory rate may indicate distress or inadequate airway clearance, not necessarily effectiveness of suctioning.
C. Oxygen saturation should be monitored but may not immediately reflect the effectiveness of suctioning.
D. Clear breath sounds indicate that the airway is patent and free of secretions, suggesting effective suctioning.
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