A 1-year-old child with respiratory syncytial virus (RSV) has been admitted to the pediatric unit. The nurse observes that the child has a fever, rhinorrhea, frequent coughing, and sneezing.
Which additional finding should alert the nurse that the child is in acute respiratory distress?
Flaring of the nares.
Bilateral bronchial breath sounds.
Diaphragmatic respirations.
A resting respiratory rate of 35 breaths/min.
The Correct Answer is A
Flaring of the nares is a sign of increased respiratory effort, which is a manifestation of acute respiratory distress. This finding occurs when the child is attempting to draw in more air to meet the increased demand for oxygen.
Bilateral bronchial breath sounds can indicate consolidation or a bronchial obstruction, but they are not specific to acute respiratory distress.
Diaphragmatic respirations are a normal finding and may occur in response to respiratory distress, but they do not necessarily indicate acute respiratory distress.
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and does not necessarily indicate acute respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When moving an adolescent with scoliosis who is recovering after a surgical spinal instrumentation, the nurse should use the log roll technique. This technique involves keeping the spine in alignment while turning the client onto their side. Crossing the arms and legs, raising the hips, and flexing the knees are not appropriate techniques for moving a client with spinal instrumentation.
Correct Answer is B
Explanation
When caring for a child in balanced suspension skeletal traction, the most important intervention for the nurse to implement is monitoring peripheral pulses and sensation in the affected leg to detect any compromise in circulation or nerve function. This is crucial because the traction places tension on the bones, which can result in nerve or vascular damage.
Changing positions every 2 hours is important to prevent pressure injuries, but it is not the most critical intervention.
Cleansing pin sites and assessing skin for redness and signs of tissue breakdown are also important, but they are not as urgent as monitoring peripheral pulses and sensation.
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