A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

Nasal flaring present.

Suprasternal retractions present.

Intercostal retractions present.

Subcostal retractions present.

Answer and Explanation

The Correct Answer is C

A. Nasal flaring present. Nasal flaring is a separate sign of respiratory distress, but it does not describe retractions.

B. Suprasternal retractions present. Suprasternal retractions occur above the sternum, not between the ribs.

C. Intercostal retractions present. Intercostal retractions occur between the ribs and indicate difficulty breathing due to increased respiratory effort.

D. Subcostal retractions present. Subcostal retractions occur below the ribcage, not between the ribs.

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Correct Answer is B

Explanation

A. Urinary frequency. Urinary frequency is an increased urge to void, which can be caused by a UTI but does not explain cloudy, foul-smelling urine on its own.

B. Urinary tract infection (UTI). Cloudy, dark amber urine with a foul odor is indicative of a UTI due to bacterial presence, pus (pyuria), and possibly hematuria.

C. Urinary retention. Urinary retention leads to distended bladder, incomplete emptying, and overflow incontinence, but it does not cause foul-smelling, cloudy urine unless it leads to secondary infection.

D. Urinary incontinence. Incontinence is the involuntary loss of urine, but it does not cause cloudy or foul-smelling urine unless there is an underlying infection.

A. When the client states they have the urge to defecate. B. Immediately before meals. C. Every 2 hr day and night. D. After every drink or meal.

Correct Answer is A

Explanation

helps train the body to respond to natural urges.

B. Immediately before meals. Although eating stimulates peristalsis, this is not the most effective approach because the client may not be ready to defecate at that time.

C. Every 2 hr day and night. A rigid 2-hour schedule is unnecessary and may cause distress or inconvenience for the client.

D. After every drink or meal. While eating may trigger the gastrocolic reflex, forcing bathroom visits after every meal or drink is not always appropriate.

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A child is being evaluated for increased work of breathing. While inspecting the child's chest, the nurse notes pulling in or sucking in of the skin between the child's ribs. How might the nurse accurately document this finding?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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