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 A

Explanation

A. Ask the client to push her legs and feet against the nurse's palms. This action directly assesses the client’s muscle strength and ability to bear weight, which is essential before ambulation.

B. Check the client's pedal pulses and feet for edema. While circulatory assessment is important, it does not assess muscle strength, which is needed for safe ambulation.

C. Ask the client if she has been out of bed today. The client’s response does not objectively measure strength or readiness for ambulation.

D. Ask the client how strong she feels today. A client’s perception of strength may not be accurate and is not an objective way to assess readiness for ambulation.

A. Having the client perform range-of-motion exercises of the arm B. Inspecting the site for reduced swelling C. Asking the client to rate the pain D. Monitoring the client's pulse rate

Correct Answer is C

Explanation

A. Having the client perform range-of-motion exercises of the arm. While movement may improve after treatment, this is not a direct measure of the effectiveness of a cold compress.

B. Inspecting the site for reduced swelling. Cold therapy reduces swelling by vasoconstriction. Swelling reduction can be an indicator of decreased inflammation but it does not provide a direct assessment of the client’s pain levels.

C. Asking the client to rate the pain. This is the most direct and reliable method to determine the effectiveness of a cold compress for pain relief.

D. Monitoring the client's pulse rate. Cold therapy does not significantly affect systemic circulation to the extent that it impacts pulse rate.

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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

A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?

Correct Answer is A

Explanation

A nurse is applying a cold compress for pain and minor swelling for a client who has a sutured laceration on the forearm. Which of the following data-collection activities should the nurse use to determine whether the treatment is effective?

Correct Answer is C

Explanation

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