The nurse assesses Josh's vital signs. His respirations are rapid and shallow.
1. What is the best technique for the nurse to use to assess Josh's respirations accurately?
A. Observe chest expansion for 15 seconds and multiply by 4
B. Encourage Josh to breath as deeply and slowly as possible C. Watch for nasal flaring and count the air exchanges with each movement D. Place a hand on Josh's chest and count the hand motion D. Place a hand on Josh's chest and count the hand motion -
Rationale: This technique allows the nurse to observe and count the chest movement, even when respirations are shallow.
Josh's respirtory rate is 36.
2. How should the nurse describe Josh's respiratory pattern?
D. Orthopnea C. Trachypnea -
Rationale: A rapid respiratory rate, which is consistent with Josh's rate of 36. Normal respiratory rate for a school-aged child is 16-30 breaths per minute.
Because of Josh's dyspnea, the nurse is concerned that he may need to receive oxygen.
3. To determine the need for the application of a nasal cannula, which assessment is most important for the nurse to perform?
A. Measure oxygen saturation
B. Auscultate breathing sounds
C. Measure capillary refill
D. Observe chest excursion 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.
4. In assessing Josh's breathing sounds, the nurse should ask him to perform which action?
A. Hold his breath for fifteen seconds
B. Repeat the phrase, "ninety-nine"
C. Cough deeply after each breath
D. Breath deeply through the mouth D. Breath deeply through the mouth -
Rationale: Josh should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breathing sound.
5. To measure capillary refill, the nurse must first perform which action?
A. Count Josh's radial pulse
B. Compress Josh's nailbed
C. Obtain a healthcare provider's prescription
D. Elevate the extremity to be assessed B. Compress Josh's nailbed -
Rationale: To measure capillary refill, the nurse should first compress the client's nailbed, and then observe the return of normal color to the nailbed.
The nurse plans to measure Josh's oxygen saturation with a spring-tension finger clip. While the nurse is explaining this procedure, Josh asks if it will hurt.
6. Which response is best for the nurse to provide?
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 squeezing your finger with your other hand." D. "You seem to be worried about experiencing pain." C. "The clip feels like squeezing your finger with your other hand." -
Rationale: This is an honest response to Josh's question regarding pain and one that places the sensation he will feel in a context he can understand.
The nurse measure Josh's oxygen saturation at 88% and capillary refill at 1 second. Breathing sounds are absent in the base and coarse bilaterally throughout the rest of the lung fields. The nurse applies a nasal cannula and administers oxygen at 2 liters per minute.
7. When applying a nasal cannula, it is most important for the nurse to provide which instructions?
A. Make sure the cannula tubing stays snugly around the ears and under the chin B. Remove the clients toy pistol from the room
C. Make sure the humidifier always contains some water
D. Keep some type of padding around the ear and over the cheeckbones B.Remove the clients toy pistol from the room-
Rationale: Oxygen supports combustion and is essential to ensure client safety during oxygen administration
8. Which nursing diagnosis is most relevant to Josh's current status?
A. Excess fluid volume
B. Impaired spontaneous ventilation
C. Impaired gas exchange...
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