A nurse is caring for a 3-year-old child in the pediatric unit.
Based on the exhibits provided, which of the following findings are consistent with the child’s condition? Select all that apply.
Hoarse voice
Nasal flaring
Increased appetite
Sitting upright and leaning forward
Decreased respiratory rate
Correct Answer : A,B,D
Choice A rationale:
A hoarse voice is consistent with the child’s condition. The child has a frequent cough and stridor, which can cause irritation and inflammation of the vocal cords, leading to a hoarse voice.
Choice B rationale:
Nasal flaring is a sign of respiratory distress. It indicates that the child is working harder to breathe, which is consistent with the observed symptoms of stridor, cough, and mild intercostal retractions.
Choice C rationale:
Increased appetite is not consistent with the child’s condition. The child is refusing to eat or drink and appears fatigued, which is typical in cases of respiratory distress and illness.
Choice D rationale:
Sitting upright and leaning forward is a common position adopted by children in respiratory distress. This position helps to open the airway and makes breathing easier.
Choice E rationale:
Decreased respiratory rate is not consistent with the child’s condition. The child’s respiratory rate has increased from 20/min to 24/min, indicating increased effort to breathe due to respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Blood should not be stored at room temperature for more than 30 minutes. The second unit should be stored in a blood bank refrigerator until needed.
Choice B rationale
Each unit of blood should be infused within 4 hours to reduce the risk of bacterial contamination.
Choice C rationale
RBCs should be administered using filtered IV tubing to prevent the infusion of clots and other debris.
Choice D rationale
Dextrose 5% in water should not be used during the infusion of packed RBCs as it can cause hemolysis. .
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
The inactivated polio virus (IPV) vaccine is typically administered at 2 months, 4 months, and 6-18 months of age, not at 12 months.
Choice B rationale
The hepatitis B vaccine is given at birth, 1-2 months, and 6-18 months of age.
Choice C rationale
The varicella (chickenpox) vaccine is recommended to be given at 12-15 months of age for the first dose.
Choice D rationale
The human papillomavirus (HPV) vaccine is recommended for preteens aged 11-12 years, not for infants.
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