A nurse is caring for a 2-year-old toddler in the pediatric unit who was admitted from the emergency department due to concerns about the child’s breathing.
Which of the following findings should the nurse on the pediatric unit identify as an indication that the treatment plan is effective? (Select all that apply)
Nasal flaring
Retractions
Oxygen saturation
Respiratory rate
Pulse
Breath sounds in bilateral bases
Heart rate
Correct Answer : C,D,F
Choice A rationale:
Nasal flaring is a sign of respiratory distress. The absence of nasal flaring would indicate improvement, but the presence of nasal flaring indicates ongoing respiratory distress.
Choice B rationale:
Retractions are also a sign of respiratory distress. The reduction or absence of retractions would indicate improvement, but their presence indicates ongoing respiratory distress.
Choice C rationale:
Oxygen saturation is a key indicator of respiratory function. An improvement in oxygen saturation levels (from 88% on room air to 94% on 2 L/min O2) indicates that the treatment plan is effective in improving the child’s oxygenation.
Choice D rationale:
Respiratory rate is an important vital sign to monitor in respiratory conditions. A decrease in respiratory rate (from 40 breaths/min to 32 breaths/min) indicates that the treatment plan is effective in reducing the child’s respiratory distress.
Choice E rationale:
Pulse rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in pulse rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.
Choice F rationale:
Breath sounds in bilateral bases are important to assess for improvement in lung function. The presence of mild bilateral expiratory wheezes and diminished breath sounds in the bases indicates some improvement compared to the initial assessment.
Choice G rationale:
Heart rate can be influenced by various factors, including fever, anxiety, and respiratory distress. While a decrease in heart rate may indicate improvement, it is not as specific an indicator of respiratory function as oxygen saturation and respiratory rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
High fever is a common finding in children experiencing sickle cell crisis. The crisis is often triggered by infections, which can cause fever. The sickled red blood cells can block blood flow, leading to tissue ischemia and necrosis, which can also contribute to fever.
Choice B rationale
Bradycardia, or a slow heart rate, is not typically associated with sickle cell crisis. The crisis usually causes an increased heart rate due to pain and the body’s stress response.
Choice C rationale
Constipation is not a common finding in sickle cell crisis. The primary symptoms are related to pain and vaso-occlusion, which can cause severe pain and other complications.
Choice D rationale
Decreased respiratory rate is not a typical finding in sickle cell crisis. The crisis can cause respiratory distress due to pain and hypoxia, leading to an increased respiratory rate.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Turning the child’s head to the side and pressing on the nasal ridge is not the recommended method for managing nosebleeds. This position can cause blood to flow into the throat, leading to swallowing blood and potential vomiting.
Choice B rationale
Sitting the child upright and leaning slightly forward while applying pressure to the sides of the nose is the correct method. This position helps prevent blood from flowing into the throat and allows it to clot more effectively.
Choice C rationale
Having the child lie flat and apply pressure to the cheeks is not effective for stopping a nosebleed. This position can cause blood to flow into the throat, leading to swallowing blood and potential vomiting.
Choice D rationale
Putting the child in bed, elevating the head slightly, and pressing on the forehead is not effective for stopping a nosebleed. The pressure needs to be applied directly to the soft part of the nose to control the bleeding.
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