Ch 40 PrepU: Nursing Care of a Family ... Respiratory Disorder

The nurse is preparing the room for a client admitted from the emergency department with suspected tuberculosis (TB). Which type of infection control precautions would the nurse anticipate?

Airborne precautions should be initiated for any client with suspected tuberculosis. Clients with suspected TB are placed away from other hospitalized clients in a single-occupancy room. Airborne precautions are implemented over droplet precautions as the bacilli can remain in the air and inhaled by others. Standard and contact precautions do not involve protecting the respiratory system.

Pancreatic enzymes are part of the treatment in cystic fibrosis. When should the nurse administer the enzymes?

Before meals and snacks with milk

Which electrolyte does the client with cystic fibrosis need in abundance?

Dietary intake of sodium is encouraged due to increased sodium losses. Clients are especially encouraged to eat salty pretzels, potato chips, etc. during hot weather or when sodium losses are anticipated.

The nurse is examining a 5-year-old. Which sign or symptom is a reliable first indication of respiratory illness in children?

Tachypnea, or increased respiratory rate, is often the first sign of respiratory illness in infants and children. Slow, irregular breathing and increasing listlessness are signs that the child's condition is worsening. Cyanosis (a bluish tinge to the lips) or the degree of cyanosis present is not always an accurate indication of the severity of respiratory involvement.

What is a definitive test for cystic fibrosis?

The definitive test in diagnosing cystic fibrosis is the sweat chloride test. This test is performed by stimulating a small patch of sweat glands on the inner aspect of the forearm. There must be two positive tests and clinical symptoms to confirm the diagnosis. The other choices are routine diagnostic tests.

The nurse is caring for a child with a history of asthma who presents to the emergency department with wheezing, tachypnea, and dyspnea. What will the nurse do first?

The nurse will first elevate the head of the 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 the 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 18-month-old client has had recurrent respiratory infections. The mother expresses concern that this child is having more complications from respiratory infections than her older children had. The nurse's best response would be:

"Air passages are small in toddlers, and when inflamed they become smaller because of edema and are occluded with mucus." Airway narrowing results from bronchial constriction, airway swelling, and mucus production. Mucus clogs small airways, trapping air. Younger children may have more infections., Air passages become blocked with mucus and are difficult to clear, but small air passages in the toddler is the best answer. Telling the parent that her older children probably have as many respiratory infections as this child is not an appropriate answer.

The pediatric unit has multiple clients experiencing upper respiratory system complications. Which pediatric client is at the highest risk for respiratory distress?

2-year-old child with epiglottitis Epiglottitis is a medical emergency due to the swelling of the epiglottis covering the larynx. This client needs frequent assessment for respiratory distress, especially since young children have smaller, more compliant airways. The 3-year-old child has more developed respiratory passages than a 2-year-old child, and although croup may cause respiratory distress, the likelihood of airway obstruction is lower when compared to epiglottitis. The 11-month-old infant has a common cold, typically from a virus. The 16-year-old adolescent with asthma has fully developed respiratory airways, which are less likely to be obstructed.

A child is brought to the emergency department late one evening and is diagnosed with croup. The child was noted to have a shrill, harsh respiratory sound when breathing in. This symptom is referred to as:

In the child with croup syndrome, inspiratory stridor (shrill, harsh respiratory sound) is often noted.

The caregivers of an 8-year-old bring their child to the pediatrician and report that the child has not had breathing problems before, but since taking up lacrosse the child has been coughing and wheezing at the end of every practice and game. Their friend's child has often been hospitalized for asthma; they are concerned that their child has a similar illness. The nurse knows that because the problems seem to be directly related to exercise, it is likely that the child will be able to be treated with:

Mast cell stabilizers are used to help decrease wheezing and exercise-induced asthma attacks. A bronchodilator often is given to open up the airways just before the mast cell stabilizer is used. Corticosteroids are anti-inflammatory drugs used to control severe or chronic cases of asthma. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma.

The nurse is caring for a 7-year-old boy who has just had a tonsillectomy. Which intervention is least appropriate for this child?

Providing fluids by straw may cause trauma to the surgical site and should be avoided. Applying an ice collar, if ordered, helps relieve pain. Placing the child on his side, until he is fully awake, facilitates safe drainage of secretions. The child should be discouraged from coughing, clearing his throat, and blowing his nose to avoid trauma to the surgical site.

The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse anticipates which test as most helpful in determining the extent of the child's hypoxia?

Pulse oximetry is a useful tool for determining the extent of hypoxia. It can be used by the nurse for continuous or intermittent monitoring. Pulmonary function testing measures respiratory flow and lung volumes and is indicated for asthma, cystic fibrosis, and bronchopulmonary dysplasia (chronic lung disease). Peak expiratory flow testing is used to monitor the adequacy of asthma control. Chest radiographs can show hyperinflation, atelectasis, pneumonia, foreign bodies, pleural effusion, and abnormal heart or lung size.

The nurse is collecting data on a child admitted with a respiratory concern. The nurse notes that the child is anxious and sitting forward with the neck extended to breathe. The signs the nurse noted indicate the child likely has:

The child with epiglottitis is very anxious and prefers to breathe by sitting forward with the neck extended. Immediate emergency attention is necessary. The child with asthma would have wheezing and distress trying to breathe. The child with cystic fibrosis would not have respiratory distress unless ill with respiratory infection. The drooling, leaning forward, and appearing distressed are not manifestations of TB.

Which test in a child with cystic fibrosis would help monitor airway function?

The pulmonary function tests help measure airway function, lung volumes, and gas exchange. Bronchoprovocation provokes bronchospasms to determine airway constriction. Peak flow measurement measures lung velocity. Pulse oximetry monitors blood level oxygen saturation.

Which postoperative nursing intervention is most appropriate for the preschool child following tonsillectomy and adenoidectomy?

assessing for frequent swallowing Frequent swallowing can be an indicator of bleeding from the surgical site. Although coughing and deep breathing, as well as use of an incentive spirometer, are important postoperative care measures for many surgical procedures, in tonsillectomy and adenoidectomy, these measures would irritate the surgical site, causing pain and promoting bleeding. Limiting fluid intake is not wise since dehydration may result, and throat dryness increases pain.

When caring for a child with acute bronchiolitis, which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

encourage fluids, administer oxygen, suction the nose, contact precautions A child with acute bronchiolitis is treated with nasal suctioning, rest, and increased fluids. Humidified oxygen may be administered via a nasal cannula, face mask, or an oxyhood (a clear plastic hood placed over the child's head) if needed. 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 child to rest. The hospitalized child is placed on contact transmission precautions to prevent the spread of infection.

If there is a foreign body in the larynx, how will the client present?

stridor A foreign body can be either solid or liquid and it can lodge in the upper or lower airways. If a child has symptoms of cough, wheezing and/or stridor, it is an indication the foreign body is obstructing the upper airway. The child with a foreign body obstruction is anxious, has difficulty talking, and may be drooling. Edema of the airways may have occurred but generalized edema is not present.

In teaching home care to parents of a child with cystic fibrosis, the nurse will emphasize:

techniques to clear the airway. Clearing tenacious mucus from the airway is important for promoting oxygenation and preventing respiratory infection, a common problem for children with cystic fibrosis. A high-fat diet would increase calorie intake, but high-carbohydrate and moderate-fat intake is preferred since fats are especially difficult for a child with cystic fibrosis to digest. Fluid intake should be encouraged to help thin secretions.

A 4-week-old infant is diagnosed with acute bronchiolitis. The parent states, "I do not know how the baby got this!" How should the nurse respond?

"Has your infant been around any crowds?" Acute bronchiolitis is caused by a viral infection, most often, respiratory syncytial virus. Viruses are often spread between groups of people in close contact. Hereditary and environmental complications do not relate to this disorder.

The nurse is caring for a 10-year-old girl with cystic fibrosis who receives pancreatic enzymes. Which comment by a parent demonstrates understanding of the instructions regarding the medication?

"I should give the enzymes before each meal or snack." The enzymes are necessary for appropriate digestion and absorption of food and nutrients. There is no interaction between enzymes and antibiotics. Large, malodorous stools are a sign of no pancreatic enzyme activity. Pancreatic enzymes must be given each time the child eats, usually in smaller doses for snacks than for meals.

A child is brought to the emergency department by his parents because he suddenly developed a barking cough. Further assessment leads the nurse to suspect that the child is experiencing croup. What would the nurse have most likely assessed?

A child with croup typically develops a bark-like cough often at night. This may be accompanied by inspiratory stridor and suprasternal retractions. Temperature may be normal or slightly elevated. A high fever, dysphagia, and toxic appearance are associated with epiglottitis.

A child is hospitalized with pneumonia. The nurse assesses an increase in the work of breathing and in the respiratory rate. What intervention should the nurse do first to help this child?

The child who is experiencing increased work of breathing should be placed in a position to better open the airway and provide more room for lung expansion. Generally this is accomplished by elevating the head of the bed. If this does not improve the work of breathing, then administering oxygen should be done. The oxygen saturation should be measured because it will provide information as to the severity of the respiratory problem, but this measurement will not directly help the child. The health care provider should be notified if the child continues to deteriorate.

The nurse is caring for a newly admitted 3-year-old child who has been diagnosed with tuberculosis. When reviewing the child's records which finding(s) is consistent with this disease? Select all that apply.

Tuberculosis is a highly contagious respiratory infection. A child who has been living in crowded locations, who is impoverished, or homeless is at an increased risk. Signs and symptoms of the disease include weight loss, night sweats, anorexia and pain. A child living in a household with parents and one sibling does not have an increased risk for infection. A sore throat is not associated with tuberculosis.

The caregivers of a child report that their child had a cold and complained of a sore throat. When interviewed further they report that the child has a high fever, is very anxious, and is breathing by sitting up and leaning forward with the mouth open and the tongue out. The nurse recognizes these symptoms as those seen with which disorder?

epiglottitis The child with epiglottitis may have had a mild upper respiratory infection before the development of a sore throat, and then became anxious and prefers to breathe by sitting up and leaning forward with the mouth open and the tongue out. The child with tonsillitis may have a fever, sore throat, difficulty swallowing, hypertrophied tonsils, and erythema of the soft palate. Exudate may be visible on the tonsils. The child with acute laryngotracheobronchitis develops hoarseness and a barking cough with a fever, cyanosis, heart failure; acute respiratory embarrassment can also result.

The nurse is caring for a newborn in the birth room and notes the infant is pink when crying but becomes cyanotic at rest. Which collaborative intervention will the nurse perform next?

insert a soft catheter tube into the nares Newborns who are pink with crying, but become cyanotic at rest, may have choanal atresia. In order to determine if the newborn has choanal atresia, the nurse should first assess if a soft catheter can pass through the nares to the stomach. Before allowing the newborn to feed, or placing the newborn under an oxyhood, or preparing for surgery, the nurse should first assess for an obstruction. Allowing the newborn to feed with a choanal atresia will result in cyanosis and possible aspiration because the newborn will be unable to breathe and feed at the same time. Placing the newborn with choanal atresia under an oxyhood will not improve cyanosis if the newborn is not able to breathe through the nose.

The nurse caring for the child with asthma weighs the child daily. What is the most important reason for doing a daily weight on this child?

to determine fluid losses During an acute asthma attack the child may lose a great quantity of fluid through the respiratory tract and may have poor oral intake because of coughing and vomiting. Theophylline administration also has a diuretic effect, which compounds the problem. Weigh the child daily to help determine fluid losses. The child's weight is used to determine medication dosages, to ensure that the child is appropriately gaining weight and growing, and that the intake is adequate. However, the most important reason for a daily weight is to determine fluid loss.

When the nurse is reinforcing teaching with the caregiver of a 3-year-old child being discharged following a tonsillectomy, the caregiver states to the nurse, "I understand why there might be bleeding in the first 24 hours, but I do not understand why there might be bleeding in 1 week or so." What is the most appropriate explanation for the nurse to give this caregiver?

"Bleeding can occur at this time because the clots dissolve and new tissue is not yet present." Hemorrhage is the most common complication of a tonsillectomy. Bleeding is most often a concern within the first 24 hours after surgery and up to the 10th postoperative day. Bleeding late postoperatively can occur when the clots dissolve and new tissue is not yet present. A tonsillectomy can be done at any age so stating that bleeding is a complication of age is incorrect. By 10 days postoperatively the child may still have a slight sore throat or have difficulty eating some solid foods so the child has not forgotten about the surgery. The pressure of coughing is most likely to cause bleeding early postoperatively. Salt will not cause bleeding and telling that to a parent is providing false information.

A community health nurse is conducting a parenting class on respiratory syncytial virus (RSV). What statement made by a parent indicates that the teaching has been successful?

An infant exposed to second- or third-hand smoke is at risk for developing respiratory syncytial virus (RSV). RSV season runs from September through April. Current treatment recommendations for RSV do not include antibiotics. Infants are susceptible to RSV much more than older children.

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?

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.

An 8-year-old with cystic fibrosis has had a noted decline on the growth chart. Which nursing intervention is best for maintaining adequate nutrition?

The best nursing intervention is a high calorie, high protein snack. Calories can be obtained from non-nutritious foods. It is not only that the client needs calories for energy, but nutrition needs to be present. Pancreatic enzymes aid in digestion so they need to be available for foods; thus they are given prior to ingestion. Sodium is encouraged due to the high sodium loss.

The nurse is caring for a child with a history of cystic fibrosis (CF). Which finding will the nurse report to the primary health care provider?

The nurse would report wheezing, as this indicates respiratory distress. Clubbing occurs with chronic respiratory illness. It is the result of increased capillary growth as the body attempts to supply more oxygen to distal body parts. Barrel chest refers to the shape the chest takes on in chronic respiratory illness. It takes the shape as chronically the lungs fill with air but are unable to fully expel the air. Delayed puberty is common in clients with cystic fibrosis and does not require reporting at this time.

The nurse is caring for an infant whose oxygen saturation levels frequently drop below 90%. Which data is most important to relate to the health care provider?

blood gases Infants may respond to low blood oxygen levels with increased respirations followed by a period of apnea. Conditions such as bronchopulmonary dysplasia (chronic lung disease), pneumonia, and bronchiolitis can put infants at risk. The health care provider needs to be kept updated on blood oxygen levels. Vital signs, respiratory depth, and pattern, and breath sounds are basic nursing assessments that provide helpful data on the respiratory system, but these data are not as important as the laboratory results.

When preparing the room for an infant with bronchiolitis, which equipment is most important?

oxygen tubing and face mask Bronchiolitis is an acute inflammatory process in the bronchioles and small bronchi. The treatment is supportive oxygen therapy, suctioning, and hydration. Rarely is a tracheostomy set needed for care. An infant is not able to use a metered dose inhaler but nebulized bronchodilators may occasionally be needed. Bronchiolitis is most commonly associated with the respiratory syncytial virus (RSV), thus antibiotics would not be warranted in the treatment plan.

A group of nurses is reviewing the diagnosis of cystic fibrosis. With regard to the effect of this disease on the body, which parts of the body (besides the lungs) are most affected by this disease?

pancreas and liver

A hospitalized child suddenly begins reporting "my chest hurts," is tachypneic, and has tachycardia. The nurse auscultates the lung sounds and finds absent breath sounds on one side. After notifying the health care provider, what action would the nurse take first?

prepare for chest tube insertion A pneumothorax is a collection of air in the pleural space. Trapped air consumes space in the pleural cavity causing a partial or complete collapse. The priority symptom a nurse would assess is the decreased or absent lung sounds on the affected side. A pneumothorax can occur spontaneously in a healthy child or it can occur in a child with chronic lung disease, who has been on a ventilator or has had thoracic surgery. Additional symptoms the child would experience would be chest pain, tachypnea, retractions, grunting, cyanosis and tachycardia. Many of these symptoms could be present with any child with acute or chronic lung disease or respiratory distress, but the defining symptom is the absent breath sounds. The treatment for a pneumothorax is with a chest tube so the priority action would be to gather supplies and prepare for the health care provider to insert a chest tube. Obtaining an oxygen saturation level measurement will only provide data, it will not help the child in distress. Oxygen may need to be administered, but with a pneumothorax, it will be very ineffective. Mechanical ventilation would be a last resort and could actually make the situation worse if the lung was not reinflated.

The nurse is reinforcing teaching with the caregivers of a child diagnosed with tuberculosis who is being treated with the drug rifampin. Which statement made by the caregivers best indicates the teaching was successful?

"While they are taking this medication, I will not worry if their tears look orange." 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 administering medications to a child with cystic fibrosis. Which method would the nurse most likely use to give medications to treat the pancreatic involvement seen in this disease?

Pancreatic enzymes should be administered at all meals and snacks to promote adequate digestion and absorption of nutrients. They are supplied in capsule form. For the infant and young child, they can be opened and sprinkled on foods such cereal, pudding, or applesauce. They also can be swallowed whole. They are not supplied in liquid form, so the child could not take them in a medication cup. They are not supplied for injection or inhalation, only oral use.

The nurse is assessing a 5-year-old girl who is anxious, has a high fever, speaks in a whisper, and sits up with her neck thrust forward. Based on these findings, what would be least appropriate for the nurse to perform?

The child is exhibiting signs and symptoms of epiglottitis, which can be life-threatening. Under no circumstances should the nurse attempt to visualize the throat. Reflex laryngospasm may occur, precipitating immediate airway occlusion. Providing 100% oxygen in the least invasive manner that is most acceptable to the child is a sound intervention, as is allowing the child to assume a position of sitting forward with the neck extended. Auscultation would reveal breath sounds consistent with an obstructed airway.

A child has been prescribed a nasal cannula for oxygen delivery. What should the nurse do before applying the cannula?

assess patency of nares A nasal cannula is a good delivery device for children because it allows them to eat and talk unobstructed. Because the device is designed for flow through the nares, the patency of the nares should be assessed prior to using the cannula. If the nares are blocked from secretions, suctioning may be required. If there is a defect in the upper airway causing blockage, the nasal cannula may not be an appropriate oxygen delivery device. The oxygen saturation should have been measured and used as a guide for the prescription of oxygen therapy. Adding humidification is a way to keep the upper airways from becoming too dry, but oxygen can be started before humidity is added. Anytime a child is sick enough to require oxygen all respiratory assessments, including lung sounds, should be done. It does not matter, however, what the lung sounds are if the child is in enough distress to require oxygen. The lung sounds can be assessed after oxygen is started.

A child with a suspected airway obstruction is brought to the emergency room. The child produces a harsh, strident sound on inspiration (stridor). Where should the nurse anticipate the obstruction is most likely to be located?

larynx When the vibrations produced as air are 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.

A child with asthma has been monitoring his peak expiratory flow rate (PEFR) and has been maintaining it within 90% of his personal best. Today, the child is experiencing symptoms and his PEFR is at 40% of his personal best. The child's mother calls the office and asks the nurse what she should do. What would the nurse instruct the mother to do first?

"Have him use his short-acting bronchodilator right away." The child's symptoms and drop in PEFR suggest a medical alert or "red" situation, indicating the need for the short-acting bronchodilator and then a trip to the office or emergency department. The child should use his short-acting bronchodilator first and then go to the physician's or nurse practitioner's office or emergency room. Waiting for a greater drop in his PEFR readings would be inappropriate because the child is experiencing an acute condition that warrants immediate attention. The child is experiencing an acute situation and requires immediate attention. A low-dose steroid inhaler would not be appropriate because it would not help his bronchospasm.

The nurse is working with a group of caregivers of small children discussing various disorders seen in children. One of the caregivers makes the statement that her children always seem to have a common cold. After discussing this condition, the caregivers make the following statements. Which statement indicates the most accurate understanding of a complication related to the common cold?

"Next time he has a cold, I will watch closely to see if my 1-year-old pulls at his ears." The most common complication of a common cold is otitis media. If the symptoms persist for several days, the child must be seen by a physician to rule out complications such as otitis media. Most young children do not have a fever with a common cold. The child may have mild diarrhea caused by mucus drainage into the digestive system, but this is not a major complication seen with the condition. The school-age child can be given acetaminophen, but pain is not a complication associated with the common cold.

The nurse is bottle feeding an infant diagnosed with pneumonia. An important action for the nurse to take is clearing the infant's nose, and then the nurse should feed the infant using:

For the infant with pneumonia, use the smallest nipple so that he or she does not choke, but also does not have to work too hard. A large-holed nipple would allow the fluids to flow too quickly and likely choke the infant. Working too hard with a small-holed nipple would wear the infant out and require the use of excessive energy. There is no need for a special nipple.

A parent with a child who has cystic fibrosis asks the nurse how to determine if the child is receiving an adequate amount of pancreatic enzymes. How should the nurse respond? Select all that apply.

Pancreatic enzymes are required for the child with cystic fibrosis (CF) to help absorb nutrients from the diet and to aid in digestion. They are given with each meal and snack the child eats. The number of capsules required at each dose depends upon the diagnosis of how the pancreas is functioning and the amount of food needed to be digested. The pancreatic laboratory values may determine a baseline for the number of pills to start with, but the dosage is adjusted regularly. The dosage of pancreatic enzymes is adjusted until an adequate growth pattern is established and the child is having no more than 1 to 2 stools per day. The child should be given an increased number of enzyme pills when a meal with high-fat content is consumed, not fewer.

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:

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 nurse is caring for a 4-month-old male client brought to the emergency department by the parents. Click to highlight the finding(s) that will require follow-up.

Symptoms of bronchiolitis include runny nose, cough, and sneezing attacks that occur slowly over a few days. Increased coughing indicates symptoms are worsening. Decreased appetite is concerning because young children can become dehydrated quickly. A change in behavior such as being "very fussy" may be an indication that the child is not feeling well. Fever may indicate an underlying infection. It is important for the nurse to know that the parents administered acetaminophen for fever reduction, because it rules out other possible underlying causes and will help guide treatment. The facts that the parents only had to change the child's diaper once since last night and there was very little urine and no feces indicates dehydration. Increased lethargy indicates a decrease in level of consciousness. Signs and symptoms of bronchiolitis include moderate clear rhinorrhea and nonproductive cough. Dry, cracked lips and mucous membranes and skin very warm and ruddy indicate dehydration. Expiratory wheezes indicate bronchial constriction. A temperature of 101.2°F (38.4°C) indicates fever and requires follow up. Intact skin is a normal finding. A heart rate of 130 beats/min is within the normal range for the child's age (80 to 140 beats/mins). A respiratory rate of 28 breaths/min is within normal range for the child's age (20 to 30 breaths/min). Oxygen saturations of 96% on room air is a normal finding for the child's age (normal range is 95% to 100%).

A nurse is caring for an infant admitted with a diagnosis of bronchiolitis. After completing an assessment, the nurse creates a plan of care for the infant. Which client goal would be priority in the plan of care?

The infant's airway will remain clear and free of mucus. Keeping the infant's airway clear is the top priority. An O2 saturation of 90% on room air is minimally acceptable. It is important that the infant's breathing be less labored and that there is decreased nasal stuffiness, but having the airway clear and free of mucus is most important.

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. Use all options.

The nurse assesses the respiratory status upon meeting the client. The nurse notes breathing difficulty, including pursed-lip breathing or use of accessory muscles, pallor, and ability to speak and breathe. The client is then arranged in bed in a semi-Fowler 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 the respiratory state. Respiratory therapy is notified that a client with dyspnea has arrived. Further orders for breathing treatments or chest physical therapy are made. Lastly, instruct the client on effective coughing techniques to remove mucus.

A 9-year-old female child was brought to the emergency department after experiencing wheezing and shortness of breath while playing soccer. The parents administered two puffs of albuterol metered dose inhaler (MDI) with little effect, and 911 was notified. Paramedics applied oxygen 2 liters by nasal cannula for oxygen saturation of 90% on room air, and administered an albuterol nebulizer treatment. Audible wheezing was heard, and a 20-gauge intravenous (IV) catheter was inserted. Vital signs upon arrival at the emergency room: temperature, 98.8°F (37.1°C); heart rate, 125 beats/min; blood pressure, 88/50 mm Hg; respiratory rate, 32 breaths/min; oxygen saturation, 92% on simple face mask. Child appears anxious.

The nurse should assess the child's airway first. Assessment should always be prioritized using the ABCs (airway, breathing, and circulation).Intravenous (IV) methylprednisolone should be administered promptly to decrease inflammation in the lungs, which will improve air flow. Circulation would be assessed after airway and breathing. Level of consciousness is simultaneously checked with ABCs (airway, breathing, and circulation), but the nurse must first perform a focused respiratory assessment and implement interventions promptly to prevent respiratory arrest. Metered-dose inhalers would not be used in status asthmaticus. Aerosol nebulizer treatments would be administered. Because the child is in severe respiratory distress, the nurse would not perform peak flow meter instruction at this time.

A 3½-year-old boy is brought to the emergency department by the parent. The parent tells the nurse, "My child started with a cold about 2 days ago, and then the fever got really high and my child reported a severe sore throat. I also noticed my child's voice got really hoarse." Further assessment reveals inspiratory stridor, drooling, and protruding tongue movements. The parent reports that the family does not believe in vaccinations. Which action does the nurse take next?

The nurse should notify the health care provider of the assessment findings because the child is exhibiting signs and symptoms of epiglottitis. Symptoms begin as those of a mild upper respiratory tract infection. After 1 or 2 days, as inflammation spreads to the epiglottis, the child suddenly develops severe inspiratory stridor, a high fever, hoarseness, and a very sore throat. Children may have such difficulty swallowing that they drool saliva. They may protrude their tongue to increase free movement in the pharynx. The epiglottis can be so severely swollen that it can obstruct the airway. If the child's gag reflex is stimulated with a tongue blade, the swollen and inflamed epiglottis can be seen to rise in the back of the throat as a cherry-red structure. It can be so edematous, however, that the gagging procedure causes complete obstruction of the glottis and shuts off the ability of the child to inhale. Therefore, in children with symptoms of epiglottitis (e.g., dysphagia, inspiratory stridor, cough, fever, and hoarseness), the nurse never attempts to visualize the epiglottis directly with a tongue blade or obtain a throat culture unless a means of providing an artificial airway, such as tracheostomy or endotracheal intubation, is immediately available.

An 8-year-old girl presents with drooling and a complaint of painful swallowing. She has a high fever and is lethargic. On examination the nurse sees that her palatine tonsils are bright red and swollen. The girl's mother says that she has never had these symptoms before. A throat culture indicates a streptococcus infection. What is the course of treatment that the nurse would expect in this situation?

These symptoms are consistent with bacterial tonsillitis. Therapy for bacterial tonsillitis includes an antipyretic for fever, an analgesic for pain, and a full 7- to 10-day course of an antibiotic such as penicillin or amoxicillin. If the cause is viral, no therapy other than comfort or fever reduction strategies is necessary. Tonsillectomy is removal of the palatine tonsils. Adenoidectomy is removal of the pharyngeal tonsils. In the past, tonsillectomy was recommended for children after an episode of tonsillitis. This is no longer recommended as tonsillar tissue is an important component of the immune system.

The nurse is doing an in-service training with nurses working with families who may be in situations that create high-risk health situations for their children. The nurse explains that children of caregivers with which situation should be tested annually for tuberculosis?

Tuberculosis screening is recommended annually for children in high-risk situations or communities, including the following: a family in which there is an active case of TB; Native American children; and children who recently immigrated from Central or South America, the Caribbean, Africa, Asia, or the Middle East. Other high-risk children are those infected with HIV, those who are homeless or live in overcrowded conditions, and those immunosuppressed from any cause.