A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply.)
Oxygen saturation 95%
Warm extremities
Wheezing
Nasal flaring
Retraction of sternal muscles
Correct Answer : C,D,E
Choice A reason: An oxygen saturation of 95% is within the normal range and does not indicate respiratory deterioration.
Choice B reason: Warm extremities are not an indication of respiratory status deterioration; they are generally a sign of good circulation.
Choice C reason: Wheezing is a common sign of airway obstruction in asthma and can indicate a deterioration in respiratory status.
Choice D reason: Nasal flaring is a sign of increased work of breathing and can indicate respiratory distress in a child with asthma.
Choice E reason: Retraction of sternal muscles is a sign of respiratory distress and can indicate a worsening condition in a child with asthma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While administering vitamins and minerals is important, it does not provide complete nutrition, especially for a client with such extensive burns and absent bowel sounds.
Choice B reason: This is the correct choice because total parenteral nutrition (TPN) provides complete nutrition intravenously, bypassing the gastrointestinal tract, which is necessary when bowel sounds are absent, indicating a non-functioning GI system.
Choice C reason: Enteral feedings require a functioning GI tract. With absent bowel sounds, this indicates a high risk for complications like aspiration or feeding intolerance.
Choice D reason: Encouraging oral intake is not feasible for a client with extensive burns and absent bowel sounds due to the high risk of inadequate intake and aspiration.
Correct Answer is B
Explanation
Choice A reason: Removing personal objects from the room is not reflective of palliative care principles, which focus on comfort and personal significance.
Choice B reason: Listening and responding to the family's discussions about their child's life aligns with the holistic approach of palliative care, which includes emotional support.
Choice C reason: Expressing personal feelings of missing the client is not indicative of an understanding of palliative care roles and responsibilities.
Choice D reason: Being hopeful about new medications is not relevant to palliative care, which focuses on quality of life rather than curative treatment.
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