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?
A resting respiratory rate of 35 breaths/minute.
Flaring of the nares.
Diaphragmatic respirations.
Bilateral bronchial breath sounds.
The Correct Answer is B
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ensuring that someone stays with the client for 24 hours is important for immediate postoperative care but does not directly ensure compliance with self-care instructions.
B. The teach-back method involves asking the client to repeat in their own words the instructions you just provided. This confirms that they understand the information correctly and are able to follow it at home. For a client with hearing difficulties, this ensures that any miscommunication is identified and corrected before discharge, improving compliance and safety.
C. Speaking clearly and facing the client for lip reading is helpful for communication but does not ensure that the client fully understands and can follow the instructions.
D. Providingwritten instructions for eye drop administrationis useful as a supplement, but written instructions may not guarantee understanding, especially if the client has visual limitations or confusion.
Correct Answer is C
Explanation
A. Progressing the diet is important but does not address immobility-related complications.
B. Maintaining the IV infusion rate is necessary but not specific to preventing complications from immobility.
C. Applying intermittent pneumatic compression devices helps prevent deep vein thrombosis (DVT), a significant risk for immobile clients post-surgery. This is a critical preventative measure for immobility-related complications.
D. Frequent pain assessments are important but do not specifically prevent complications from immobility.
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