The nurse should identify which of the following findings as an improvement in the child's condition?

The following orders are expected: A, B, C, E. The following orders are unexpected: D.

Choice A rationale

An NPO status is an expected order for a client undergoing a procedure such as a major surgery, which necessitates an empty stomach to prevent aspiration during anesthesia. This order is a safety precaution to ensure the client’s respiratory tract is protected from gastric contents. This reduces the risk of aspiration pneumonia, a serious complication of anesthesia.

Choice B rationale

Bed rest is an expected order for clients with a medical condition that requires a reduction in physical activity to promote healing, conserve energy, or prevent complications. For example, a client with a cardiac condition, a client recovering from surgery, or a client with a high risk of falls would be ordered to remain on bed rest to minimize physiological stress.

Choice C rationale

A blood type and cross match is an expected order for a client who may require a blood transfusion. This is a critical safety step to ensure the blood to be transfused is compatible with the client’s blood, preventing a potentially fatal transfusion reaction. This test is routinely ordered prior to major surgeries or in cases of significant blood loss.

Choice D rationale

Cold compresses are generally unexpected for most systemic conditions unless a localized inflammation or injury is the primary issue. For example, cold compresses are used to reduce swelling and pain from sprains or burns, not typically for systemic conditions requiring other treatments. A systemic or internal issue does not respond well to localized cold application.

Choice E rationale

Morphine IV is an expected order for a client experiencing severe pain, such as post-operative pain or pain from a traumatic injury. Morphine is a powerful opioid analgesic that provides effective and rapid pain relief by binding to opioid receptors in the central nervous system. The IV route ensures a quick onset of action.

Choice A rationale

An increased respiratory rate following suctioning is typically a sign that the procedure was ineffective or caused respiratory distress. Effective suctioning should clear the airway, leading to a more regular and often decreased respiratory rate, as the child no longer needs to work as hard to breathe. Tachypnea can indicate airway irritation or continued obstruction.

Choice B rationale

A decrease in oxygen saturation indicates a worsening of the child's respiratory status. Effective suctioning should improve gas exchange by clearing secretions from the airway, leading to an increase in oxygen saturation. A drop in oxygen levels can occur if the suctioning process is too prolonged or if it causes bronchospasms, both of which are adverse outcomes.

Choice C rationale

Clear breath sounds are a primary indicator that the airway has been effectively cleared of secretions. Suctioning removes mucus and other fluids that can cause adventitious sounds like rhonchi or crackles. The absence of these sounds and the presence of clear, bilateral breath sounds confirm that the procedure has successfully improved air flow and ventilation to the lungs.

Choice D rationale

An increase in oral secretions after suctioning is not a direct measure of the procedure's effectiveness. While suctioning can sometimes stimulate a cough and increase secretions temporarily, the primary goal is to clear the lower airway. Increased oral secretions might indicate a need for further oral suctioning but do not confirm that the tracheostomy tube and lower airways are clear.

Choice E rationale

While a cough can be stimulated during suctioning and is a normal protective reflex, an increase in coughing after the procedure is not a direct measure of effectiveness. Persistent coughing may indicate airway irritation or a continued presence of secretions. The most reliable indicator of a clear airway is the change in breath sounds and the child's overall respiratory effort.