A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Administer oxygen to the client.

Notify the charge nurse.

Document client findings and interventions taken.

Place the client in high Fowler's position.

Answer and Explanation

The Correct Answer is D,A,B,C

D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.

A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.

B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.

C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.

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Correct Answer is A

Explanation

A. Anterior fontanel closed. The anterior fontanel typically closes between 12 to 18 months of age. Closure at 4 months is premature and may indicate conditions such as craniosynostosis, which can affect skull and brain development. The provider should be notified for further evaluation.
B. Moves objects to mouth. This is an expected developmental milestone for a 4-month-old infant. At this age, infants begin to grasp objects and bring them to their mouths as part of their sensory exploration.
C. Rolls from back to abdomen. Most infants begin rolling from back to abdomen around 5 to 6 months. If a 4-month-old achieves this milestone early, it is not necessarily concerning but rather an indication of advanced motor development.
D. Posterior fontanel closed. The posterior fontanel typically closes between 6 to 8 weeks of age, so closure by 4 months is expected and does not require provider notification.

A. "I can stop giving my child this medication if he is taking a steroid." B. "I will give this medication to my child once daily in the evening." C. "It takes 2 months of scheduled use before this medication is effective." D. "I will give this medication to my child every 2 hours if he is wheezing."

Correct Answer is B

Explanation

A. "I can stop giving my child this medication if he is taking a steroid." Montelukast is a leukotriene receptor antagonist used for long-term asthma management and should not be discontinued without consulting a provider. It can be used alongside inhaled corticosteroids for better asthma control.
B. "I will give this medication to my child once daily in the evening." Montelukast is typically administered once daily in the evening because leukotrienes contribute to airway inflammation and bronchoconstriction, which can be more pronounced at night. Evening administration maximizes its effectiveness in preventing asthma symptoms.
C. "It takes 2 months of scheduled use before this medication is effective." Montelukast begins to show effects within a few days to a few weeks of consistent use, not two months. However, it is not a rescue medication and should be taken regularly for long-term asthma control.
D. "I will give this medication to my child every 2 hours if he is wheezing." Montelukast is not a rescue medication and does not provide immediate relief for acute bronchospasms. A short-acting beta-agonist, such as albuterol, should be used for rapid symptom relief during wheezing episodes.

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A nurse enters a client's room and finds the client experiencing respiratory distress. Place the following interventions in the order in which the nurse should perform them. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?

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