A nurse is caring for a 16-year-old adolescent who just received rescue medication for an asthma exacerbation. Prior to the medication administration. nursing assessment revealed tearfulness, a respiratory rate of 32/min, wheezing in all lobes, oxygen saturation level of 91% on room air. inability to speak. and nasal flaring. The nurse should recognize that which of the following manifestations would indicate the client's condition is improving?
is sitting calmly and able to answer questions
Downward trend of oxygen saturation level
Upward trend in respiratory rate
Changes positions frequently
The Correct Answer is A
Rationale:
A. Being calm and able to speak indicates relief of respiratory distress, improved air movement, and adequate oxygenation, signs of improvement.
B. A downward trend in oxygen saturation would indicate worsening of the condition.
C. An increasing respiratory rate signals ongoing or worsening respiratory distress.
D. Frequently changing positions suggests the patient is still trying to compensate for difficulty breathing, not improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Offering choices, when appropriate, actually decreases noncompliance by giving the child a sense of control.
B. Giving pediatric clients limited choices (e.g., “Do you want your medicine with apple juice or water?”) empowers them, reduces anxiety, and promotes trust and cooperation with care.
C. Offering choices does not impact the length of the hospital stay.
D. While it may improve cooperation during medication administration, it does not eliminate the need for it.
Correct Answer is A
Explanation
Rationale:
A. Regression in development for six months, especially in gross motor skills, is abnormal and concerning. It may indicate a neurological or developmental issue and requires further evaluation.
B. Temporary regression such as incontinence during illness or hospitalization is common and expected.
C. Sleep disturbances due to environmental changes like moving are normal for infants.
D. Regression when starting daycare is a normal stress response and usually resolves.
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