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The nurse is educating a group of parents about respiratory disorders in young children. One of the
mothers tells the nurse that she has noticed her child's nostrils flaring when a child has a respiratory
infection. The mother asked the nurse if she should be concerned. What is the most appropriate
response by the nurse?
A. "nasal flaring occurs when a child has to work hard to breathe."
B. "A child exhibiting nasal flaring should be seen by a physician."
C. "When a child is breathing deeply, nasal flaring will occur."
D. "Nasal flaring is a common respiratory symptoms in children and adults."
A. Nasal flaring occurs when a child has to work hard to breathe.
The nurse assessment of a 6-month-old infant brought to the outpatient clinic reveals a respiratory rate
of 52 breaths/min, retractions, and wheezing. The mother states that her infant was doing fine until
yesterday. Which action would be the most appropriate?
A. Administer a nebulizer treatment
B. Send to the infant for a chest radiograph
C. Refer the infant to the emergency department
D. Provide teaching about cold care to the mother
C. Refer the infant to the emergency department
,A nurse is caring for an infant being treated for an upper respiratory infection. The physician would like
to order a series of x-rays for the infant who has been in a foster home for four months. How should the
nurse obtained consent?
A. Obtain consent from the foster parents
B. Call child protective services
C. Contact the child's biological parent
D. Contact the units director of nursing
A. Obtain consent from the foster parents
A nurse is caring for a toddler in respiratory distress requiring endotracheal intubation. When gathering
supplies, which item should the nurse obtain that is most important for this child?
A. uncuffed endotracheal tube
B. curved blade laryngoscope
C. pain medication
D. nasogastric tube
A. uncuffed endotracheal tube
A 2-year-old client is brought to the emergency department with suspected croup. The client appears
frightened and cries as the nurse approaches him. The nurse needs to assess the client's breath sounds.
The best way to approach the client is to"
A. expose the client's chest quickly and auscultate breath sounds as quickly and efficiently as possible.
B. ask the caregiver to wait briefly outside until the assessment is over.
C. tell the client the nurse is going to listen to the chest with the stethoscope.
D. allow the client to handle the stethoscope before the nurse listens to the client's lungs.
D. allow the client to handle the stethoscope before the nurse listens to the client's lungs.
,The nurse at the clinic is assessing a toddler and notices retractions while the child is breathing. The
parents state that they began to notice the retractions a few days ago and wondered if it was significant.
What is the best response by the nurse?
A. "Retractions occur normally when children are very active."
B. "This is very serious; you should have brought your child in sooner."
C. "Your child is having difficulty breathing and we need to determine why."
D. "This is an indication that your child has a respiratory infection."
C. "Your child is having difficulty breathing and we need to determine why."
A nurse at a community event is called to an unresponsive 3-year-old. The parent states the child was
eating a hot dog. The nurse determines the child has an obstructed airway. After instructing an observer
to call 911, what intervention should happen first?
A. performing the Heimlich maneuver until the child starts choking or coughing
B. opening the child's mouth and attempting to give 2 breaths
C. delivering five back blows followed by five chest thrusts
D. performing chest compressions with the heel of one hand 30 times
D. performing chest compressions with the heel of one hand 30 times
Which signs and symptoms would lead the nurse to suspect a child has tetralogy of Fallot (TOF)? Select
all that apply.
-murmur
-history of squatting
-bounding pulse
-cyanosis
-faint pulse
-tachypnea
-history of squatting
-cyanosis
, -tachypnea
-murmur
Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory
distress? Select all that apply.
-coughing
-respiratory rate of 35 breaths/minute
-heart rate of 95 beats/minute
-restlessness
-malaise
-diaphoresis
-coughing
-respiratory rate of 35 breaths/minute
-restlessness
-diaphoresis
An adolescent with well-controlled type 1 diabetes has assumed complete management of the disease
and wants to participate in gymnastics after school. To ensure safe participation, the nurse should
instruct the client to adjust the therapeutic regimen by:
A. eating a snack before each gymnastics practice.
B. measuring urine glucose level before each gymnastics practice.
C. measuring blood glucose level after each gymnastics practice.
D. increasing morning dosage of intermediate-acting insulin.
A. eating a snack before each gymnastics practice.