NURSG 125 Breathing Patterns Case Study Guide: Pediatric Respiratory Assessment & Nursing Interventions Questions with Answers & detailed rationale

A comprehensive nursing case study focusing on pediatric respiratory assessment, breathing patterns, and nursing interventions. Covers techniques for evaluating respirations, pulse oximetry, oxygen administration, care planning, therapeutic communication, documentation, specimen collection, and medication administration in a clinical setting. Ideal for nursing students and educators in courses like NURSG 125. 1. Meet The Client - ANSWER-A mother brings her 9-year-old to the Emergency Department (ED) because he is short of breath and unable to sleep, due to coughing. Section 1 Assessment Skills The practical nurse (PN) evaluates the client's vital signs. Respirations are rapid and shallow. What technique should the nurse use to accurately evaluate the child's respirations? A. Observe chest expansion for 15 seconds and multiply by 4. B. Encourage the client to breathe as deeply and slowly as possible. C. Watch for nasal flaring and count the air exchanges with each movement. D. Place hands flat against the back or chest and observe the rise and fall of the chest. - ANSWER-D. Place hands flat against the back or chest and observes the rise and fall of the chest. Rationale: This technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow. 2. Because of the client's dyspnea, the nurse is concerned that they may need to receive oxygen. Which action should the nurse perform that would be most indicative of the need for supplemental oxygen? A. Measure oxygen saturation B. Auscultate breath sounds C. Measure capillary refill D. Observe chest expansion - ANSWER-A. Measure oxygen saturation Rationale: Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen, a valuable reflection of the client's overall oxygenation. 3. When auscultating breath sounds, the nurse should demonstrate and ask the child to perform which action? A. Hold their breath for fifteen seconds while auscultating. B. Extend their arm to observe the color of the nailbeds. C. Cough deeply after each breath. D. Breathe deeply through the mouth. - ANSWER-D. Breathe deeply through the mouth. Rationale: The child should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds. 4. The client's mother states that this is the third time in recent months she has brought her child to the ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or other infections the child has had within the past year. What is the nurse's purpose for this question? A. To assess for suspected child neglect or abuse. B. To explore the possibility of antibiotic resistance developing. C. To assess for possible immune deficiency disorder. D. To explore the need for a primary care provider to avoid ED visits. - ANSWER-C. To assess for possible immune deficiency disorder. Rationale: By 5 years of age a child should have developed immunity to many types of infections. It they continue to have reccurent infections it may be a sign of immune deficiency which will need further investigation. 5. To measure capillary refill, the nurse must first perform which action? A. Count the radial pulse rate. B. Compress the nails of one finger until it blanches. C. Place child supine while counting respirations. D. Elevate the extremity to be assessed. - ANSWER-B. Compress the nails of one finger until it blanches. Rationale: To measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the nailbed. Section 2 Pulse Oximetry The nurse plans to measure the child's oxygen saturation with a spring-tension finger clip. 6. While the nurse is explaining this procedure, the client asks if it will hurt. Which response by the nurse is best? A. Yes, but the pain will only last a very short time. B. No, you will not even know the clip is on your finger. C. The clip feels like a clothespin squeezing your finger. D. You seem to be worried about experiencing pain. - ANSWER-C. The clip feels like a clothespin squeezing your finger. Rationale: This is an honest response to the child's question regarding pain and one that places the sensation they will feel in a context he can understand. The nurse measures the child's oxygen saturation at 88% and capillary refill at 1 second. Breath sounds are absent in the bases and coarse bilaterally throughout the rest of the lung fields. The nurse initiates application of a nasal cannula and administers oxygen at 2 L/min per facility protocol.