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 ["A","B","C","D","E"]

Explanation

The incision dressing is dry and intact, with no bleeding noted: This indicates that the surgical site is healing well without any signs of infection or complications. A dry and intact dressing suggests that there is no active bleeding or wound drainage, which is a positive sign of wound healing.

The client has tolerated clear liquids post-recovery and has advanced to a soft diet: Progression from clear liquids to a soft diet indicates that the client's gastrointestinal function is returning to normal. This progression suggests that there are no immediate concerns regarding postoperative nausea, vomiting, or bowel obstruction.

The client has ambulated around the unit and tolerated activity well: Ambulation and tolerance of activity demonstrate the client's physical mobility and overall strength. Being able to move around the unit without difficulty suggests that the client is recovering well from the surgical procedure and is regaining strength and function.

Bowel sounds are present in all 4 quadrants, and the client has passed flatus: The presence of bowel sounds in all four quadrants indicates normal gastrointestinal motility and function. Passing flatus is another positive sign of gastrointestinal recovery, suggesting that the client's bowels are active and functioning properly post-surgery.

Pain is tolerated with analgesia orally: The client's ability to tolerate pain with oral analgesia indicates effective pain management and suggests that the surgical incision site is not causing significant discomfort or distress. Effective pain control is essential for postoperative comfort and can facilitate the client's recovery process.

A. Fluid volume deficit. B. Caregiver role strain. C. Bowel incontinence. D. Impaired bed mobility.

Correct Answer is A

Explanation

A. Diarrhea can lead to significant fluid and electrolyte imbalances, especially in older adults. Prioritizing hydration and electrolyte management is essential to prevent severe complications like renal failure or shock.
B. While caregiver stress is significant and must be addressed, it is not as immediately life-threatening as a fluid volume deficit.
C. This is an ongoing management issue but does not pose an immediate threat to the client's life compared to fluid and electrolyte imbalances.
D. Although important for overall care and prevention of complications such as pressure ulcers, it is not as critical as managing fluid volume deficit in this scenario.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E"]

Explanation

The nurse identifies several problems for an older adult client experiencing diarrhea and fecal incontinence who is confined to bed and being cared for by a primary caregiver. In planning care, the nurse should determine which nursing problem is the highest priority?

Correct Answer is A

Explanation

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