Unit 2: NR328 - Nursing care: pediatric respiratory alterations

Which client is at the most risk for experiencing a severe respiratory illness?

6-month-old

The nurse is reviewing the history of a 4-year-old client in a health care provider's office. Which risk factors impact the likelihood of the child experiencing a respiratory illness? Select all that apply.

ALL

Match the respiratory clinical manifestation with the corresponding cause.

Barking cough - croup finger clubbing - cystic fibrosis stridor - epiglottitis wheezing - asthma whooping cough - pertussis

For each potential health care provider order, indicate if the order is a priority, needed, or contraindicated. ​

Priority - Administer corticosteroid Administer oxygen Administer short-acting bronchodilator Needed - Administer antipyretic, Perform chest x-ray Contraindicated - perform chest physical therapy via vest

The nurse is caring for an adolescent client admitted with an asthma exacerbation. A short-acting bronchodilator and corticosteroids were administered. Which assessment finding should the nurse report to the health care provider immediately?​

peak flow 35% of normal

The nurse is caring for a 9-month-old with respiratory syncytial virus (RSV). The infant's pulse oximetry is 89% and copious amounts of thick nasal drainage are present. Which two actions should the nurse perform first?

suction nares, instill saline drops

The nurse is caring for an adolescent client who has asthma. Which assessment finding requires immediate action by the nurse?

wheezing

For each client finding, indicate if it is consistent with the disease process of cystic fibrosis, pneumonia, or asthma. Each finding may support more than one disease process. ​

Cough - All Decreased oxygen saturation - all elevated temperature - pneumonia SOB - all Wheezing - CF, asthma

The nurse is preparing to enter a 2-year-old client's room who has respiratory syncytial virus (RSV). For each piece of personal protective equipment (PPE), indicate if the PPE is needed or not needed. ​

Face mask - needed N95 - not needed gloves - needed gown - needed foot covers - not needed

The nurse is providing education over the phone to a parent of an infant with a respiratory illness. For each recommendation, specify whether it is indicated or contraindicated.

Indicated - Administer acetaminophen per the label instructions for fever. Monitor the number of wet diapers the infant has in a 24-hour period. Observe for signs of worsening respiratory distress. Use saline drops and suction nose as needed using a nasal aspirator. Contraindicated - Use a topical vapor rub on the chest.

The nurse is admitting a 2-month-old to the pediatric unit who presents with tachypnea, tachycardia, grunting, retractions, nasal flaring, and a sunken anterior fontanelle. Which orders does the nurse anticipate from the health care provider? Select all that apply.

Intravenous (IV) maintenance fluids Nothing by mouth status Continuous cardiopulmonary monitoring Intravenous (IV) fluid bolus Continuous pulse oximetry

Select the 5 findings that require follow up by the nurse.​

Temperature Respiratory rate​ Oxygen saturation​ Heart rate​ Breath sounds

The nurse is educating a caregiver on how to care for respiratory infections at home. Which instruction(s) should the nurse include in the education? Select all that apply.

all except encourage physical activity

The child is most at risk for --- as evidenced by the client's ----

impaired gas exchange, pulse oximetry

For each assessment finding, select whether the finding indicates that the client's condition is improved, declined, or unchanged. ​

improved - pulse ox declined - breath sounds unchanged - RR, temp

the nurse should first --- and then ---

initiate oxygen, administer albuterol