A nurse is assessing a 4-year-old client admitted to the pediatric unit for respiratory distress. Which of the following findings should be addressed immediately?
Stridor during inspiration.
A wet, productive cough.
A fever of 38.5°C (101.3°F).
Irritability reported by the caregiver.
The Correct Answer is A
Choice A rationale: Stridor during inspiration is a high-pitched, harsh sound caused by an upper airway obstruction. This is a critical finding that requires immediate attention, as it indicates compromised airflow potentially due to conditions like croup, epiglottitis, or foreign body aspiration. Left untreated, the obstruction can worsen, leading to severe hypoxia or respiratory failure. Prompt evaluation and intervention, such as securing the airway, are essential to ensure the child's safety and prevent life-threatening complications.
Choice B rationale: A wet, productive cough is typically associated with lower respiratory tract infections, such as bronchitis or pneumonia. While it warrants medical attention and treatment, it is not an immediate threat to the airway or oxygenation compared to stridor. Management often includes supportive care, hydration, and possibly antibiotics. However, this finding does not pose the acute risk that stridor represents in terms of respiratory distress and airway compromise.
Choice C rationale: A fever of 38.5°C (101.3°F) is a common finding in pediatric clients with infections. It indicates an inflammatory response to illness but is not immediately life-threatening. Fever management involves antipyretics, hydration, and monitoring for signs of more severe infection or sepsis. While elevated temperature requires attention, it does not carry the same urgency as stridor, which signals potential airway obstruction.
Choice D rationale: Irritability reported by the caregiver is a nonspecific symptom that may result from various causes, including pain, discomfort, or fever. While it suggests the child may be unwell, it does not directly indicate a critical condition or imminent danger. Monitoring and addressing the underlying cause of irritability are important, but this finding does not necessitate the same immediate response as stridor, which directly affects airway patency and oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A low carbohydrate, high-fat diet is not suitable for toddlers with cystic fibrosis. This condition requires meeting increased metabolic demands, making carbohydrate restriction detrimental to energy balance.
Choice B rationale
High-protein, high-calorie diets are ideal for toddlers with cystic fibrosis due to their higher basal metabolic rate and nutrient malabsorption. These diets support growth and immune function despite the disease.
Choice C rationale
Moderate protein, low-calorie diets are inappropriate for cystic fibrosis management. Insufficient caloric intake exacerbates malnutrition and can lead to failure to thrive in affected children.
Choice D rationale
High-fat, low-protein diets neglect the importance of balanced nutrition required for growth. While fat content is important, adequate protein intake is equally crucial for muscle development. .
Correct Answer is D
Explanation
Choice A rationale: Steatorrhea during stool analysis, characterized by greasy, foul-smelling stools due to excess fat, is typically associated with malabsorption syndromes such as cystic fibrosis or chronic pancreatitis. While this warrants further evaluation, it is not directly linked to acute respiratory symptoms such as difficulty breathing or coughing up blood. Thus, this finding does not necessitate immediate intervention compared to the urgent risks posed by hemoptysis.
Choice B rationale: Barrel chest, often associated with chronic obstructive pulmonary disease (COPD), reflects long-term structural changes due to chronic air trapping. While it is an important finding requiring ongoing management, it is not an acute issue demanding urgent intervention. It does not directly explain symptoms like hemoptysis or respiratory distress, which indicate more critical underlying conditions requiring immediate attention.
Choice C rationale: An oxygen saturation of 95% on 1 L oxygen via nasal cannula is within the acceptable range for most individuals, with normal oxygen saturation values typically between 95% and 100%. This finding does not indicate severe hypoxemia or a deteriorating respiratory status. As such, it does not require urgent intervention compared to significant bleeding in the respiratory tract.
Choice D rationale: Hemoptysis of 300 mL is a critical finding requiring urgent intervention. This volume of blood indicates severe hemorrhage in the respiratory tract, which can compromise the airway, lead to hypovolemic shock, and cause respiratory failure if not addressed promptly. Immediate evaluation is necessary to identify the source of bleeding and initiate lifesaving treatments such as airway stabilization and hemorrhage control.
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