Nokea
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.
You may also like to solve these questions
What will the nurse discourage when providing education to parents of a child with asthma? (Select all that apply.)
- A. Stuffed toys
- B. Pet ownership
- C. Gymnastics
- D. Basketball
- E. Cotton blankets
Correct Answer: A,B,D
Rationale: Stuffed toys and pet ownership can trigger asthma due to allergens, and basketball requires prolonged energy output, which may exacerbate symptoms.
The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask how to prevent this from happening with the child they are currently expecting. What will the nurse explain as the best way to prevent BPD?
- A. Maternal intake of folic acid
- B. Exercise
- C. Prevention of preterm birth
- D. Provision of oxygen therapy to the newborn
Correct Answer: C
Rationale: The prevention of preterm birth is the best way to prevent BPD, as it is associated with prematurity and prolonged ventilation.
The teaching plan for the use of a dry powder inhaler for the treatment of asthma should include the warning to rinse the mouth after inhaling the powder. What does this prevent?
- A. Discoloration of tooth enamel
- B. Halitosis
- C. Irritation of oral membranes
- D. Candidiasis
Correct Answer: D
Rationale: Inhalant powders can cause candidiasis (yeast) infection of the mouth.
Which is the most appropriate nursing action when planning care for a child with cystic fibrosis?
- A. Provide chest physiotherapy before meals every day.
- B. Assess weight monthly.
- C. Administer pancreas with protein food at mealtime.
- D. Ensure high-protein, high-calorie diet.
Correct Answer: D
Rationale: The maintenance of adequate nutrition is essential. The diet is high in protein and calories.
The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in either of their families has CF. What is the nurse's best response based on the understanding of CF?
- A. Only one parent carries the CF gene.
- B. Both parents are carriers of the CF gene.
- C. The inheritance pattern is multifactorial.
- D. The result is probably a genetic mutation.
Correct Answer: B
Rationale: Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the disease.