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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. While physical activity is important for overall health, it may not directly address constipation. Increasing fluid and fiber intake is a more specific intervention.

B. Stool softeners can be helpful, but dietary modifications should be attempted first before resorting to medications.
C. Gas-producing foods may not be directly related to constipation. The focus should be on promoting regular bowel movements through diet and hydration.
D. Increasing fluid and fiber intake is a recommended first-line approach for managing constipation in older adults.

A. Monitor the amount of drainage from the client's incision. B. Observe both lower extremities for redness and swelling. C. Evaluate the client's ability to use an incentive spirometer. D. Palpate all peripheral pulse points for volume and strength.

Correct Answer is B

Explanation

A. Monitoring incision drainage is important for infection and wound healing but not directly related to the effectiveness of compression devices.
B. Observing both lower extremities for redness and swelling directly assesses the effectiveness of the pneumatic compression devices in preventing deep vein thrombosis (DVT).
C. Evaluating the use of an incentive spirometer is important for respiratory function but unrelated to the compression devices.
D. Palpating peripheral pulse points is useful for circulation assessment but does not specifically evaluate the prevention of DVT, which is the primary purpose of the compression devices.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

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Correct Answer is B

Explanation

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