Chapter 20: Alterations in Respiratory Function

A nurse is conducting a presentation for a community parent group about respiratory conditions in children. The nurse determines that the teaching was successful when the group identifies which of the following as one of the most common conditions seen during early childhood? A. Croup B. Bronchiolitis C. Asthma D. Pneumonia

ANS: A Rationale: Croup is one of the most common acute respiratory conditions seen during early childhood (6 months to 5 years of age), with a peak in the second year of life, and the most common cause of upper airway obstruction

The nurse is performing a well-child assessment on a 2-week-old infant. The nurse asks why her baby only breathes out of his nose and does not seem to mouth breathe. What information can the nurse provide to the mother? A. "Babies breathe from both their nose and mouth around 2 or 3 weeks of age." B. "Breathing from the nose only will be noted in newborns for about the first 6 weeks of life." C. "Your baby is breathing normally for his age." D. "Babies are nose breathers for about the first 4 weeks of life."

ANS: D Rationale: Newborns are obligatory nose breathers until at least 4 weeks of age. The young infant cannot automatically open his or her mouth to breathe if the nose is obstructed. The nares must be patent for breathing to be successful while feeding. Newborns breathe through their mouths only while crying.

The nurse is caring for a 2-year-old diagnosed with bacterial pneumonia. The child has been placed in a mist tent. In caring for the child, it is important for the nurse to: A. monitor the child regularly for signs of cyanosis. B. avoid contact with the mist if the nurse is a sexually active female of childbearing age. C. use contact transmission precautions. D. check for hyperthermia related to enclosure in the tent.

ANS: A Rationale: In some treatment of bacterial pneumonia a croupette or mist tent is used. Children have become cyanotic in mist tents, with subsequent arrest, due to the lack of visibility while in the tent; the child must be constantly observed. Ribavirin, an antiviral drug that may be used to treat certain children with RSV, is administered as an inhalant by hood, mask, or tent; it has a high risk for teratogenicity (causing damage to a fetus) so care must be taken when the drug is administered. In treating a client with bacterial pneumonia, the client may need to be placed on infection control precautions according to the policy of the health care facility, and the nurse should look for hyperthermia related to the infection process.

The nurse is caring for a child who has been admitted with a possible diagnosis of tuberculosis. Which laboratory/diagnostic tools would most likely be used to help diagnose this child? A. Purified protein derivative test B. Sweat sodium chloride test C. Blood culture and sensitivity D. Pulmonary functions test

ANS: A Rationale: Purified protein derivative tests are used to detect TB. Sweat sodium chloride tests are used for determining the diagnosis of cystic fibrosis. Blood culture and sensitivity is done to determine the causative agent as well as the anti-infective needed to treat an infection. Pulmonary function tests are diagnostic tools for the child with asthma and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs.

A 5-year-old girl who was already admitted to the hospital for an unrelated condition suddenly becomes irritable, restless and anxious. These may be early signs of respiratory distress in a child if accompanied by: A. tachypnea. B. retractions. C. cyanosis. D. clubbing of fingers

ANS: A Rationale: Restlessness, irritability, and anxiety result from difficulty in securing adequate oxygen. These might be very early signs of respiratory distress, especially if accompanied by tachypnea (an increased respiratory rate). Retractions can be a sign of airway obstruction but occur more commonly in newborns and infants than in older children. Cyanosis (a blue tinge to the skin) indicates hypoxia, which may be a sign of airway obstruction but would not be the first. Children with chronic respiratory illnesses often develop clubbing of the fingers, a change in the angle between the fingernail and nailbed because of increased capillary growth in the fingertips. Clubbing would not occur in an acute airway obstruction, as is indicated in the scenario above.

A child who is experiencing an exacerbation of asthma is brought to the emergency department by his parents. When reviewing the child's laboratory and diagnostic test results, which is consistent with the diagnosis? A. Hyperinflation of lungs on chest radiograph B. Increased peak expiratory flow rate C. Low arterial blood carbon dioxide level D. Decreased pulmonary function tests

ANS: A Rationale: The chest radiograph usually reveals hyperinflation. Peak expiratory flow rate usually is decreased during an exacerbation. With arterial blood gases, carbon dioxide retention is usually noted. Although pulmonary function tests are useful in determining the degree of disease, they are not useful during an attack.

When caring for children with respiratory issues in relationship to the anatomy and physiology of the child's respiratory system, it is important to recognize which of the following? A. The diameter of the child's trachea is about the size of the child's little finger. B. As soon as the child is born, respiratory passages needed during fetal life close. C. Full development of the lungs and respiratory organs involved does not occur until the child is an adolescent. D. The newborn uses the thoracic muscles to breathe, and as they grow they begin using the abdominal muscles to breathe.

ANS: A Rationale: The diameter of the infant's and child's trachea is about the size of the child's little finger. This small diameter makes it extremely important to be aware that something can easily lodge in this small passageway and obstruct the child's airway.

A child with a suspected airway obstruction is brought to the emergency room. He produces a harsh, strident sound on inspiration (stridor). Where is the obstruction likely to be located, based on this information? A. In the larynx B. Lower trachea C. Bronchioles D. Pharynx

ANS: A Rationale: The vibrations produced as air is forced past obstructions such as mucus in the nose or pharynx, the noise produced is a snoring sound (rhonchi). If the obstruction is at the base of the tongue or in the larynx, a harsher, strident sound on inspiration (stridor) occurs. If an obstruction is in the lower trachea or bronchioles, an expiratory whistle sound (wheezing) occurs.

The nurse is assisting in the development of a plan of care for a child with asthma. In planning care, many goals would be appropriate for this child and/or family caregiver. Which two goals would be the highest priority for this child or family? A. The child will maintain a clear airway. B. The child will have adequate fluid intake. C. The child and family will connect with families living with the same diagnosis. D. The child and family will improve knowledge and understanding of varied pharmacologic options. E. The child will maintain adequate pain control.

ANS: A, B Rationale: Treatment and management of asthma centers around avoiding triggers and controlling inflammatory episodes. Keeping the airway open is always the priority (ABCs). The next physiologic need is adequate fluid intake. These are priorities over psychosocial considerations such as connecting with other families. Pain is not normally an issue. The family does not need to understand every available pharmacologic option. They need to understand the action plan for their child.

When caring for a child with acute bronchiolitis which nursing interventions should be included in the plan of care. Select all that apply. A. Encourage fluids B. Administer oxygen C. Place child in mist tent D. Administer antibiotics E. Follow contact precautions F. Encourage activity

ANS: A, B, C, E Rationale: The child is treated with high humidity by mist tent, rest, and increased fluids. Oxygen may be administered. Antibiotics are not prescribed because the causative organism is a virus. IV fluids often are administered to ensure an adequate intake and to permit the infant to rest. The hospitalized child is placed on contact transmission precautions to prevent the spread of infection.

A parent calls the "on call" line stating that her infant has had a bark-like cough for the past three nights. The parent states no fever or cold symptoms. Which suggestions may save a trip to the emergency department? Select all that apply. A. Use a cool mist humidifier in the infant's room. B. Take the infant into a steamy bathroom. C. Provide the infant cold oral fluids. D. Use the coolness of the night air. E. Assess throat for throat obstruction.

ANS: A, B, D Rationale: The goal of the nurse is to provide suggestions which decrease the bark-like cough and relieve the bronchial constriction. Once this is accomplished, the infant can rest. Common suggestions are use of a cool mist humidifier, steamy bathroom, and coolness of the night air.Cold fluids may cause further spasm. The parent would not be instructed to assess the throat unless data suggested a problem in that location. More likely, the parent would be instructed to bring the infant to the emergency department.

A school-age child with asthma has cromolyn sodium added to the medication regimen. What should the nurse include when teaching the child and parents about this medication? Select all that apply. A. Use this medication with a metered-dose inhaler. B. Take this medication before an inhaled bronchodilator. C. Repeat doses of this medication until symptoms subside. D. This medication is to be used for an acute asthma attack. E. Wait 1 to 2 minutes between puffs when taking this medication.

ANS: A, E Rationale: Cromolyn sodium should be used with a metered-dose inhaler, and the child should wait 1 to 2 minutes between puffs when taking this medication. This medication should be taken after a bronchodilator. Doses should not exceed the number of ordered puffs because tolerance can develop. This medication is not effective in an acute attack.

The nurse is reinforcing teaching with the family caregivers of a child diagnosed with tuberculosis who is being treated with the drug rifampin. Which statement made by the caregivers indicates an understanding of this medication? A. "My son will have to take this medication the rest of his life." B. "While she is taking this medication, I won't worry if her tears look orange." C. "This medication may cause slight bleeding when she urinates." D. "He will not be able to attend school for the first few months that he is on this medication."

ANS: B Rationale: Rifampin is tolerated well by children, but causes body fluids such as urine, sweat, tears, and feces to turn orange-red. Drug therapy is continued for 9 to 18 months. After drug therapy has begun, the child or adolescent may return to school and normal activities. Although the urine may be orange-red, this does not indicate bleeding. If bleeding with urination presents, then it should be reported and followed up on.

The nurse is caring for a child with history of asthma who presents to the emergency department with wheezing, tachypnea, and dyspnea. What will the nurse do first? A. Ask what may have triggered the attack. B. Place the child in high-Fowler's position. C. Assess the child's pulse oximetry reading. D. Apply oxygen via nasal cannula at 2 liters.

ANS: B Rationale: The nurse will first elevate the head of bed to improve the child's ability to breathe. Elevating the head of the bed allows the diaphragm to expand, consequently maximizing ventilation and oxygenation. After elevating the head of bed, the nurse will assess the pulse oximetry and apply oxygen if needed. After stabilizing the child, the nurse can ask what may have triggered the asthma attack.

The nurse is teaching a 14-year-old child on the proper use of a metered-dose inhaler to control symptoms of asthma. Which teaching points should the nurse include in these instructions? Select all that apply. A. Take two puffs at a time. B. Shake the canister before using. C. Wait 5 minutes between puffs. D. Hold the breath for 5 to 10 seconds. E. Activate the inhaler while taking a deep breath.

ANS: B, D, E Rationale: The nurse should instruct the child to shake the canister, exhale deeply, activate the inhaler while inhaling, take a long slow inhalation, and then hold the breath for 5 to 10 seconds. The child should be instructed to take only one puff at a time and to wait for 1 minute between puffs.

The NICU nurse is caring for a preterm neonate with respiratory distress syndrome on mechanical ventilation. Which assessment data would alert the nurse that a pneumothorax might have developed? Select all that apply. A. Neonate's blood pressure is 80/50. B. The neonate's respiratory rate is 68. C. Oxygen saturation is 92% and heart rate is 130. D. Neonate is exhibiting nasal flaring and grunting. E. Chest radiography reveals low lung volume and a ground-glass appearance. F. The neonate's chest is asymmetrical. with decreased breath sounds on one side.

ANS: B, D, F Rationale: Signs of pneumothorax include respiratory rate of 68, nasal flaring and grunting, asymmetrical chest rise with decreased breath sounds on one side. Infants with a pneumothorax exhibit signs of respiratory distress, including tachypnea (>60 breaths/minute) and nasal flaring and grunting. On examination the chest is asymmetrical, with decreased breath sounds on the affected side. In the case of a large pneumothorax, the nurse should observe for hypotension (systolic blood pressure<30), hypoxemia (<90%), and bradycardia (<120 beats/minute) that may occur due to an increase in pressure inside the thorax, which in turn leads to decreased cardiac output. Blood pressure of 80/50 is within normal limits. Oxygen saturation of 92% and heart rate of 130 are also within normal limits. Chest radiography revealing low lung volume and a ground glass appearance are expected in newborn respiratory distress syndrome, but is not diagnostic of a pneumothorax. A chest X-ray of a pneumothorax will show a darkened area over the collapsed lung.

Which piece of equipment is most helpful in determining airway obstruction in the client with asthma? A. A nebulizer B. An inhaler C. A peak flow meter D. An incentive spirometer

ANS: C Rationale: The peak flow meter provides the most reliable early sign of an asthma episode. Most episodes begin gradually, and a drop in peak flow can alert the client to begin medications before symptoms actually are noticeable. A nebulizer and inhaler treat symptoms. An incentive spirometer is used for lung expansion, especially after surgery.

When assessing a child for the probable cause of acute bronchiolitis, the nurse focuses on which factor? A. Bacterial infections B. Environmental allergies C. Prenatal complications D. Viral infections

ANS: D Rationale: Acute bronchiolitis is caused by a viral not bacterial infection. Neither allergies nor prenatal complications contribute to the development of this disorder.

The nurse has received morning report on a group of pediatric clients. Which pediatric client will the nurse see first? A. an infant with rhinorrhea, coughing, and oxygen saturation of 92% B. a toddler with a temperature of 100.1°F (38°C), and a harsh, barking cough C. a preschool child with crackles in the right lower lobe and chest pain D. a school-age child with dysphagia, drooling, and a hoarse voice

ANS: D Rationale: The child with signs and symptoms of epiglottitis should be seen first because epiglottitis is an emergency that can quickly cause airway obstruction. A child with signs of bronchiolitis with an oxygen saturation of 92% is more stable than this child with epiglottitis. A toddler with signs of croup is more stable than this child with epiglottitis. A child with signs and symptoms of pneumonia is more stable than this child with epiglottitis.

The emergency department nurse is caring for a client with cystic fibrosis who is dyspneic and has a productive cough. Place in order the nursing interventions performed upon arrival to improve breathing. A. Notify respiratory therapy. B. Assess respiratory status. C. Obtain oxygen saturation reading. D. Place in bed in a semi-Fowler's position. E. Place on oxygen at 2 liters. F. Instruct on energy conservation measures.

ANS:B, D, C, E, A, F Rationale: The nurse assesses the respiratory status upon meeting the client. The nurse notes breathing difficulty, including purse lip breathing or use of accessory muscles, pallor, and ability to speak and breathe. Chronic signs of hypoxia such as clubbing of the fingers and a barrel chest can be noted. The client is then arranged in bed in a semi-Fowler's position with the upper half of the body elevated 90 degrees. An oxygen saturation reading is obtained, indicating status without oxygen, and the oxygen as a nursing measure is applied at a base of 2 liters due to respiratory state. Respiratory therapy is notified that a dyspneic client has arrived. Further orders for breathing treatments or chest physical therapy are made. Lastly, instruct on effective coughing techniques to remove mucus.