A parent brings a 4-month-old infant to the clinic.
The infant has had a runny nose, a slight fever, and a cough for the last two days.
Which of the following findings should alert the nurse that the child is in acute respiratory distress?
Diaphragmatic respirations.
Resting respiratory rate of 35 breaths/min.
Bilateral bronchial breath sounds.
Flaring of the nares.
The Correct Answer is D
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Serum albumin levels can be relevant in assessing nutritional status and the body’s ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage.
Choice B rationale
Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.
Choice C rationale
Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.
Choice D rationale
Neutrophil count is a key laboratory value to note when a client with a full-thickness burn has purulent drainage at the wound. An elevated neutrophil count can indicate an infection, which could be the cause of the purulent drainage.
Correct Answer is B
Explanation
Choice A rationale
A lung biopsy is an invasive procedure that is typically performed to diagnose conditions such as lung cancer or interstitial lung disease. It is not the first-line test for evaluating increased shortness of breath in a client with COPD56.
Choice B rationale
Spirometry is a common, non-invasive test used to assess lung function and is particularly useful in conditions like COPD. It measures the volume and speed of air a person can inhale and exhale, which can help in assessing the severity of COPD56.
Choice C rationale
Antibody testing is typically used to diagnose conditions related to the immune system, such as allergies or autoimmune diseases. It is not typically used to evaluate shortness of breath in a client with COPD56.
Choice D rationale
A sweat test is used to diagnose cystic fibrosis by measuring the amount of salt in a person’s sweat. It is not used to evaluate shortness of breath in a client with COPD56.
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