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What classic sign would the nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, expect to find?
- A. Fine crackles
- B. Coarse rhonchi
- C. Expiratory wheezing
- D. Decreased breath sounds at lung bases
Correct Answer: C
Rationale: The child experiencing an acute asthma attack wheezes as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced.
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What will the nurse tell parents of a child with a positive throat culture for group A hemolytic streptococcus that the treatment is most likely to be?
- A. Acetaminophen and plenty of fluids
- B. Oral penicillin for 10 days
- C. Penicillin until his sore throat is gone
- D. Streptococcus immunization
Correct Answer: B
Rationale: When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished.
The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would indicate the child is experiencing increased respiratory obstruction?
- A. Restlessness
- B. Tachycardia
- C. Brassy cough
- D. Expiratory wheezing
Correct Answer: A
Rationale: Restlessness is a primary sign of increased respiratory obstruction.
What would the nurse teaching an asthmatic child the technique of pursed-lip breathing include? (Select all that apply.)
- A. Inhale deeply through nose with mouth closed.
- B. Make exhalation twice as long as inhalation.
- C. Use medicated inhaler prior to perform breathing exercise.
- D. Exhale through mouth as if whistling.
- E. Exhale forcefully.
Correct Answer: A,B,D
Rationale: The technique requires that breath be inhaled through the nose and exhaled through pursed lips in a nonforceful manner.
When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the nurse immediately report?
- A. Respiration rate decreases from 40 to 32 breaths/minute
- B. Heart rate decreases from 110 to 100 beats/minute
- C. Quiet chest' from previous assessment of wheezing
- D. Oxygen saturation of 90%
Correct Answer: C
Rationale: A 'quiet chest' after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest.
The asthmatic child who has been taking theophylline complains of stomachache and tachycardia and is sweating profusely. What does the nurse recognize as the cause of these symptoms?
- A. Severe asthma attack
- B. Allergic response to theophylline
- C. Onset of bronchitis
- D. Drug toxicity
Correct Answer: D
Rationale: The symptoms described are the signs of theophylline toxicity.