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. Pink-tinged hematuria is expected after the procedure, but reporting should be directed at increased bleeding or other signs of complications.
B. While some activity restrictions are necessary, a complete restriction of all physical activities is generally not advised and can lead to other complications like blood clots or decreased mobility.
C. An incentive spirometer is typically used to prevent respiratory complications post-surgery, but it is not specifically related to nephrolithotomy procedures.
D. Monitoring the urinary output is crucial because decreased output can indicate a blockage or other complications related to the nephrostomy tube.

A. Rounded spine from head to hips without concave curves. B. Posterior curvature that is convex in the thoracic area. C. Excessive concave curvature of the lumbar spine. D. Lateral curvature that creates asymmetry of the shoulders.

Correct Answer is C

Explanation

A. This describes a normal spine alignment.

B. This describes kyphosis, not lordosis.

C. Lordosis is an excessive inward curvature of the lumbar spine, often called "swayback."
D. This describes scoliosis, not lordosis.

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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

The nurse is preparing a client for discharge who underwent a percutaneous nephrolithotomy with nephrostomy tube placement. Which instruction should the nurse include in the client's postoperative discharge teaching?

Correct Answer is D

Explanation

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student's screening record?

Correct Answer is C

Explanation

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