A nurse is preparing to apply a pulse oximeter to a child who is having an acute asthma attack. Select the areas the nurse can correctly place the pulse oximeter.
(Select All that Apply.)
Foot
Forearm
Earlobe
Fingertip
Toe
Cheek
Cheek
Correct Answer : A,C,D,E
A. Foot: Suitable for infants or younger children, especially in cases of limited upper extremity access.
B. Forearm: Not a typical placement site for pulse oximetry due to lack of adequate perfusion.
C. Earlobe: Often used when peripheral sites are unreliable, especially in cases of poor circulation.
D. Fingertip: The most common site for older children or adults.
E. Toe: Frequently used in infants or small children.
F. Cheek: Not a standard site for pulse oximeter placement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Expiratory Wheezing: Expiratory wheezing is a classic sign of an asthma attack. It occurs due to narrowing and inflammation of the airways, which causes turbulent airflow during exhalation. Wheezing typically gets louder during expiration as the airways are more constricted during this phase of breathing.
B. Fine Crackles: Fine crackles are often heard in conditions like pneumonia or heart failure, where fluid is present in the lungs. They are not a hallmark of asthma.
C. Coarse Rhonchi: Coarse rhonchi are low-pitched sounds often associated with mucous secretions in the larger airways, but they are not the classic finding in asthma, where wheezing predominates.
D. Decreased Breath Sounds at the Lung Bases: Decreased breath sounds can indicate severe respiratory distress or a condition like pleural effusion or atelectasis. However, in asthma, breath sounds are usually more prominent during wheezing and are not typically decreased in the absence of complications.
Correct Answer is A
Explanation
A. Avoid a diet consisting of primarily milk: Cow's milk is low in iron and can interfere with the body's ability to absorb iron from other sources. A diet primarily consisting of milk can lead to iron deficiency anemia in young children. Therefore, it's important to offer a variety of iron-rich foods.
B. Limit intake of high-protein foods: High-protein foods are important for growth and development and should not be restricted unless there is a specific medical reason. This recommendation would not be helpful in preventing iron deficiency anemia.
C. Administer fat-soluble vitamins daily: Fat-soluble vitamins (A, D, E, and K) are essential, but they do not play a direct role in preventing iron deficiency anemia. The primary focus should be on iron-rich foods and not supplements unless indicated.
D. Include whole grains and legumes in the diet: Whole grains and legumes are healthy foods that can provide iron, but they are also high in phytates, which can interfere with iron absorption. While they should be part of a balanced diet, they alone are not sufficient to prevent iron deficiency anemia. Iron-rich foods like meat, fortified cereals, and leafy greens should be emphasized.
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