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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.
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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 nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A). What might this indicate?
- A. Bleeding from the surgical site
- B. Pain at the incision area
- C. Sore throat from postnasal drip
- D. Potential vomiting
Correct Answer: A
Rationale: Hemorrhage is the most common postoperative complication. Blood trickling down the back of the child's throat could cause frequent swallowing.
What should the nurse explain to the parent of a child with exercise-induced asthma about when to inhale Cromolyn?
- A. Before exercise to prevent attacks
- B. At the initial onset of the attack
- C. During the attack to relieve symptoms
- D. As often as 4 times a day
Correct Answer: A
Rationale: Anti-inflammatory inhalants are taken before exercise to prevent attacks.
The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). What significant information would the nurse include?
- A. Wrapping the infant snugly for rest periods
- B. Positioning the infant prone for sleep
- C. Sitting the infant up in an infant seat
- D. Placing infants on their backs or sides for sleep
Correct Answer: D
Rationale: The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS.
What is the best intervention for the nurse caring for a child experiencing an acute asthma attack?
- A. Offer plenty of fluids, particularly carbonated beverages.
- B. Place the child in a humidified cool mist tent with oxygen.
- C. Administer sedatives as ordered to decrease anxiety.
- D. Position the child with arms resting on the overbed table.
Correct Answer: D
Rationale: This position is comfortable and allows maximum use of the accessory muscles for breathing.