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Exhibits

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?

Heart rate 121 beats/minute

Capillary refill 2 seconds

Respirations 28 breaths/minute with shallow breathing

Radial and pedal pulses 2+

Severe abdominal pain in right lower quadrant

Feels anxious

Temperature 100.8° F (38.2° C)

Vomiting small amounts of green bile

Blood pressure 115/76 mm Hg

Answer and Explanation

Correct Answer : A,C,E,G,H

A.   Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B.   Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.

C.   A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D.   Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E.   Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F.   Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G.   Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H.   Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I.   A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.

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Correct Answer is ["B","H"]

Explanation

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

A. A resting respiratory rate of 35 breaths/minute. B. Flaring of the nares. C. Diaphragmatic respirations. D. Bilateral bronchial breath sounds.

Correct Answer is B

Explanation

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B.Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C.Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D.Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

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Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","H"]

Explanation

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Correct Answer is B

Explanation

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Exhibits

The nurse is caring for the client.

Which of the following assessment findings should the nurse prioritize?