A parent rushes their 3-year-old child to the emergency department with an asthma exacerbation.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Diaphragmatic respirations.
Bilateral bronchial breath sounds.
Flaring of the nares.
A resting respiratory rate of 35 breaths/minute.
The Correct Answer is C
Choice A rationale
Diaphragmatic respirations are a normal breathing pattern and do not indicate respiratory distress. In fact, diaphragmatic breathing can be beneficial for patients with respiratory conditions as it helps to maximize lung expansion and improve oxygenation. Therefore, this finding is not indicative of acute respiratory distress in a child with asthma.
Choice B rationale
Bilateral bronchial breath sounds are usually heard over the large airways, such as the trachea and the main bronchi, and are not typically associated with acute respiratory distress. Wheezing or diminished breath sounds would be more indicative of airway obstruction and respiratory distress in a child with asthma.
Choice C rationale
Flaring of the nares is a sign of increased respiratory effort and is commonly seen in children with acute respiratory distress. This indicates that the child is struggling to breathe and is using additional muscles to help with respiration, which is a concerning sign that requires immediate attention.
Choice D rationale
A resting respiratory rate of 35 breaths per minute is elevated for a 3-year-old child but is not the most specific sign of acute respiratory distress. While tachypnea can indicate respiratory distress, other signs, such as nasal flaring, retractions, and cyanosis, are more specific indicators of the severity of the child's condition. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Covering the lesion with a dressing is not an appropriate action as it will not prevent the transmission of herpes to the newborn. Herpes simplex virus can be transmitted to the neonate during delivery, and covering the lesion does not eliminate the risk.
Choice B rationale
Blood cultures are not indicated for managing active herpes lesions in a client with spontaneous rupture of membranes. This action does not address the immediate risk of transmission of the virus to the newborn.
Choice C rationale
Preparing for a cesarean section is the appropriate action because it reduces the risk of neonatal herpes transmission. Neonatal herpes can lead to severe complications, and a cesarean section is recommended to minimize the risk of exposure to the virus during vaginal delivery.
Choice D rationale
Administering penicillin is not appropriate for treating herpes lesions. Penicillin is an antibiotic effective against bacterial infections, but herpes is caused by a virus. Antiviral medications are required to manage herpes infections.
Correct Answer is ["25"]
Explanation
Step 1: Calculate the total daily dose in mg: 25 kg × 10 mg/kg/day = 250 mg/day.
Step 2: Determine how many mL are needed to administer the 250 mg dose: (250 mg ÷ 50 mg) × 5 mL = (5) × 5 mL = 25 mL. Final calculated answer: 25 mL.v
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