The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
Have the child blow a cotton ball and have the parent catch it.
Place a toy in the child's hands while listening to the breath sounds.
Offer the child bubbles before the stethoscope is placed.
Allow the child to use a stethoscope on a stuffed animal.
The Correct Answer is D
To ensure the cooperation of a preschooler during an assessment of lung sounds, the nurse can allow the child to use a stethoscope on a stuffed animal. This helps the child understand what is happening and feel more comfortable with the procedure. Having the child blow a cotton ball (A), placing a toy in the child's hands (B), and offering bubbles (C ) may distract the child but do not directly involve them in the procedure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Flaring of the nares is a sign of increased respiratory effort, which is a manifestation of acute respiratory distress. This finding occurs when the child is attempting to draw in more air to meet the increased demand for oxygen.
Bilateral bronchial breath sounds can indicate consolidation or a bronchial obstruction, but they are not specific to acute respiratory distress.
Diaphragmatic respirations are a normal finding and may occur in response to respiratory distress, but they do not necessarily indicate acute respiratory distress.
A resting respiratory rate of 35 breaths/min is within the normal range for a 1-year-old child and does not necessarily indicate acute respiratory distress.
Correct Answer is C
Explanation
Answer: C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10/L).
Rationale:
A. White blood cell count of 10,000/mm³ (10 x 10⁹/L): This is within the normal range for an infant, indicating no immediate concern for infection or immune response. It does not need to be urgently conveyed to the surgeon.
B. Weight gain of 2 pounds (0.91 kg) since birth: This is a positive sign indicating healthy growth and nutritional status, but it is not a critical concern that would affect the immediate surgical plan.
C. Red blood cell count of 2.3 cells/mcl or (2.3 x 10⁹/L): This low RBC count indicates anemia, which is critical information for the surgeon. Anemia can increase the risk of complications during and after surgery due to potential issues with oxygenation and healing, making it the most important information to convey.
D. Urine specific gravity is 1.011: This indicates normal hydration status and is not immediately relevant to the surgical procedure. It does not need to be urgently reported to the surgeon compared to the low RBC count.
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