N126 HESI Case Study: Breathing Patterns

The antitussive medication label reads, "Take 2 teaspoonfuls every 4 hours as needed." The nurse gives the client some mL medication cups and teaches the client and his mother how to pour the medication into the mL cup. To what mL level should the medication be poured? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

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Section 11 Case OutcomeThe client is discharged from his HCP's care and is happy to resume his normal activities with no further cough or dyspnea. Previous Section

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Meet the Client A mother brings her 9-year-old to the Emergency Department (ED) because he is short of breath and unable to sleep, due to coughing. Important to Know 1. Your first answer is the one that counts towards your score, but you'll be prompted to try again if you get the wrong answer. When you get the right answer, you'll go to the next section. 2. If you choose to re-take a Case Study, you will no longer be able to see your previous score.

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The HCP prescribes a complete blood count (CBC) as a part of the diagnostic workup. Which is the best explanation for the HCP's prescription? A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults. A CBC is obtained so that the HCP can rule out the possibility of appendicitis. Anemia is suspected, so a CBC is drawn to measure hemoglobin and hematocrit. Sickle cell anemia is suspected and must be identified by a CBC to begin treatment

A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults. Rationales: A CBC is obtained to assess for an elevated WBC count, which is a common finding in pneumonia except in older adults. The HCP is concerned that the child may have pneumonia. White blood cell count increases with infection, inflammation, stress, traumaPotter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P. 239) Elsevier. A CBC is obtained so that the HCP can rule out the possibility of appendicitis. The client has no signs or symptoms of appendicitis, which include right lower quadrant pain, fever and a rigid abdomen. The HCP is concerned that the child may have pneumonia. White blood cell count increases with infection, inflammation, stress, traumaPotter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P. 239) Elsevier. Anemia is suspected, so a CBC is drawn to measure hemoglobin and hematocrit. While the client has decreased oxygenation, anemia also causes fatigue and somnolence, which are not part of the assessment findings. The HCP is concerned that the child may have pneumonia. White blood cell count increases with infection, inflammation, stress, traumaPotter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P. 239) Elsevier. Sickle cell anemia is suspected and must be identified by a CBC to begin treatment There are no signs or symptoms of sickle cell anemia, which is a hereditary disease characterized by joint pain. The HCP is concerned that the child may have pneumonia. White blood cell count increases with infection, inflammation, stress, traumaPotter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P. 239) Elsevier.

Section 9 Medication AdministrationThe HCP determines that the client has a respiratory tract infection and prescribes an oral antibiotic and an oral liquid antitussive. The client's mother questions the prescription for the antibiotic. The HCP states that the child should "Take 2 pills for the first dose, followed by 1 pill every 12 hours." The mother asks the nurse if this seems right. How should the nurse respond? This sounds like a mistake. Take 1 pill with each dose. Two pills every 12 hours is the usual dose. Let me contact the pharmacist to clarify these directions. A large first dose allows the medication to start working faster.

A large first dose allows the medication to start working faster. Rationales: This sounds like a mistake. Take 1 pill with each dose. This will lead to the administration of an inaccurate dose. A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream. Potter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P. 442) Elsevier. Two pills every 12 hours is the usual dose. This will lead to the administration of an inaccurate dose. A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream.Potter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P. 442) Elsevier. Let me contact the pharmacist to clarify these directions. This is not necessay. A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream.Potter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P. 442) Elsevier. A large first dose allows the medication to start working faster. A large first dose, called a loading dose, is often used to achieve a therapeutic level more rapidly in the bloodstream.Potter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P. 442) Elsevier.

When auscultating breath sounds, the nurse should demonstrate and ask the child to perform which action? Hold their breath for fifteen seconds while auscultating. Extend their arm to observe the color of the nailbeds. Cough deeply after each breath. Breathe deeply through the mouth.

Breathe deeply through the mouth. Rationales: Hold their breath for fifteen seconds while auscultating. The nurse will not be able to hear air movement if the child holds their breath.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 99 ) Elsevier. Extend their arm to observe the color of the nailbeds. Cyanosis, a bluish coloring of the skin most easily observed in the nailbeds and lips, is a very late indicator of hypoxia. This does not require ausculatation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 99) Elsevier. Cough deeply after each breath. Coughing may be beneficial to observe for sputum, however does not allow for observation of lung sounds.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 99 ) Elsevier. Breathe deeply through the mouth. The child should be instructed to breathe slowly and deeply through a slightly opened mouth to allow best auscultation of breath sounds.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 99) Elsevier.

To measure capillary refill, the nurse must first perform which action? Count the radial pulse rate. Compress the nailbed of one finger until it blanches. Place child supine while counting respirations. Elevate the extremity to be assessed.

Compress the nailbed of one finger until it blanches. Rationales: Count the radial pulse rate. Counting pulse is not a step in obtaining capillary refill. To measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the nailbed.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 101 ) Elsevier. Compress the nailbed of one finger until it blanches. To measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the nailbed.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 101 ) Elsevier. Place child supine while counting respirations. Counting respirations is not a step in obtaining capillary refill. To measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the nailbed.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 101 ) Elsevier. Elevate the extremity to be assessed. Elevating the extremity is not a step in obtaining capillary refill. To measure capillary refill, the nurse should first compress the client's nailbed, then note how many seconds it takes for the return of normal color to the nailbed.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 101 ) Elsevier. Submit Previous Section

Upon further observation, the nurse describes the child's sputum as tenacious. To what does tenacious refer? Color. Odor. Frequency. Consistency.

Consistency. Rationales: Color. Tenacious does not refer to color. Sputum with a thick consistency may be described as tenacious (sticking together).Williams, P. (2021). deWitt's Fundamental Concepts and Skills for Nursing (6th ed. P. 533, 906). Elsevier. Odor. Tenacious does not refer to odor. Sputum with a thick consistency may be described as tenacious (sticking together).Williams, P. (2021). deWitt's Fundamental Concepts and Skills for Nursing (6th ed. P. 533, 906). Elsevier. Frequency. Tenacious does not refer to frequency. Sputum with a thick consistency may be described as tenacious (sticking together).Williams, P. (2021). deWitt's Fundamental Concepts and Skills for Nursing (6th ed. P. 533, 906). Elsevier. Consistency. Sputum with a thick consistency may be described as tenacious (sticking together).Williams, P. (2021). deWitt's Fundamental Concepts and Skills for Nursing (6th ed. P. 533, 906). Elsevier.

Section 4 Monitoring Oxygen Saturation To achieve the desired outcome, the nurse has initiated the prescribed oxygen therapy. After applying the nasal cannula, the nurse plans to attach a disposable sensor pad to measure the oxygen saturation continuously. What action should the nurse implement prior to applying the sensor? Determine if child has a latex allergy. Clean the site with an iodine solution. Milk the capillary blood flow of the site. Apply gauze padding to protect the skin.

Determine if child has a latex allergy. Rationales: Determine if child has a latex allergy. The disposable sensor pads may be made of latex. If they are, the nurse should confirm that the client does not have a latex sensitivity or allergy.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 95, 104 ) Elsevier. Clean the site with an iodine solution. This is a non-invasive procedure. Cleansing the site with an antiseptic solution is not necessary.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P.104 ) Elsevier. Milk the capillary blood flow of the site. This technique is not used to obtain oxygen saturation readings.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 104) Elsevier. Apply gauze padding to protect the skin. Padding is not necessary to protect the skin, and it may interfere with measurement of the oxygen saturation.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 104 ) Elsevier.

The nurse measures the child's oxygen saturation at 88% and capillary refill at 1 second. Breath sounds are absent in the bases and coarse bilaterally throughout the rest of the lung fields. The nurse initiates application of a nasal cannula and administers oxygen at 2 L/min per facility protocol. Prior to applying a nasal cannula in the ED, which action is most important for the nurse to implement to ensure client safety? Ensure the bed is in low position and the call light is within reach. Determine that all electrical equipment in the room is functioning correctly and is properly grounded. Use aseptic technique to prevent contamination when applying the cannula. Use petroleum gel on the cannula prongs to prevent irritating the nostrils.

Determine that all electrical equipment in the room is functioning correctly and is properly grounded. Rationales: Ensure the bed is in low position and the call light is within reach. These are important safety actions, but do not relate to the application of a nasal cannula.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 568 ) Elsevier. Determine that all electrical equipment in the room is functioning correctly and is properly grounded. An electrical spark in the presence of oxygen can result in a serious fire.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 568 ) Elsevier. Use aseptic technique to prevent contamination when applying the cannula. Clean technique, not aseptic, is used when applying a nasal cannula in this situation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 568 ) Elsevier. Use petroleum gel on the cannula prongs to prevent irritating the nostrils. Petroleum-based products can degrade the plastic of the nasal prongs and may plug the openings as well, so it is best to lubricate with a water-based gel for comfort.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 568 ) Elsevier.

After determining the priority nursing diagnoses, what step should the nurse take next in developing the plan of care? Determine the need for client teaching. Reassess for any changes. Implement the priority nursing actions. Establish goals and expected outcomes.

Establish goals and expected outcomes. Rationales: Determine the need for client teaching. The nurse should determine the need for client teaching while gathering data and establishing the priority diagnoses.Ladwig, G., Ackley, B., Makic, M.B. F. (2020). Mosby's guide to nursing diagnosis. (pp. 351). Elsevier. Reassess for any changes. This is not the correct step in the nursing process that is used following data analysis.Ladwig, G., Ackley, B., Makic, M.B. F. (2020). Mosby's guide to nursing diagnosis. (pp. 351). Elsevier. Implement the priority nursing actions. The nurse must first use another step of the nursing process before the implementation of nursing actions.Galura, S., Haugen, N. (2020). Ulrich & Canale's nursing care planning guides (8th ed. pp. 124). Elsevier. Establish goals and expected outcomes. After analysis of the data to prioritize nursing diagnoses, the nurse should establish nursing care goals and expected outcomes.Ladwig, G., Ackley, B., Makic, M.B. F. (2020). Mosby's guide to nursing diagnosis. (pp. 165). Elsevier.

Which documentation best reflects the nurse's objective assessment? The client's mother reports that he has been coughing up large amounts of sputum. His deep cough produces a small amount of pale yellow sputum. The client seems anxious and short of breath. Cough is frequent, and the client produces some yellow sputum when he coughs.

His deep cough produces a small amount of pale yellow sputum. Rationales: The client's mother reports that he has been coughing up large amounts of sputum. This is subjective data based on reported information.Williams, P. (2021). deWitt's Fundamental Concepts and Skills for Nursing (6th ed. P. 59-60 ). Elsevier. His deep cough produces a small amount of pale yellow sputum. This is an objective report of the nurse's observations. This documentation provides a thorough description of the cough and the sputum produced.Williams, P. (2021). deWitt's Fundamental Concepts and Skills for Nursing (6th ed. P. 59-60 ). Elsevier. The client seems anxious and short of breath. This documentation provides some objective data, but it is incomplete.Williams, P. (2021). deWitt's Fundamental Concepts and Skills for Nursing (6th ed. P. 59-60 ). Elsevier. Cough is frequent, and the client produces some yellow sputum when he coughs. This provides some objective data, but it is incomplete.Williams, P. (2021). deWitt's Fundamental Concepts and Skills for Nursing (6th ed. P. 59-60 ). Elsevier. Submit

Section 3 Nursing Plan of Care The nurse assists with the creation of a plan of care. Which nursing diagnosis is most relevant to the client's current status? Excess fluid volume. Inability to sustain spontaneous breathing. Impaired gas exchange. Decreased cardiac output.

Impaired gas exchange. Rationales: Excess fluid volume. Although the client is producing a large amount of sputum, he is not exhibiting any symptoms of systemic fluid volume overload.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 604) Elsevier. Inability to sustain spontaneous breathing. The child's altered respiratory function is not severe enough to be described as unable to maintain respiration sufficient to ensure basic needs.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 604) Elsevier. Impaired gas exchange. Normal saturation is 95 to 100%. The child's oxygen saturation is well below normal, indicating that his gas exchange is impaired.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 604) Elsevier. Decreased cardiac output. The assessment information provided does not support this diagnosis.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 604) Elsevier.

Section 8 Laboratory Specimen Collection Since the child has a productive cough, the HCP orders a sputum specimen be obtained and sent to the lab for culture and sensitivity. When assisting the child to obtain a sputum specimen, what action should the nurse take? Instruct and demonstrate how to cough deeply from the chest and spit into the specimen cup. Gently wipe a sterile, cotton-tipped applicator along the back of the oropharynx. Insert a soft-tipped catheter through the nares to suction secretions. Use a hard-tipped Yankauer catheter device to remove oral secretions.Potter, P., Perry, A., Stockert, P., Hall, A. (2021). Fundamentals of Nursing (10th ed. pp. 922). Elsevier.

Instruct and demonstrate how to cough deeply from the chest and spit into the specimen cup. Rationales: Instruct and demonstrate how to cough deeply from the chest and spit into the specimen cup. This technique is the least invasive and will provide sputum rather than mucus. A client who is alert, able to follow directions, and has a productive cough can obtain a specimen without the use of an invasive catheter.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 200 ) Elsevier. Gently wipe a sterile, cotton-tipped applicator along the back of the oropharynx. This technique is not used for sputum cultures. To collect sputum have client take full inhalation followed immediately by a forceful cough, expectorating sputum directly into specimen containerPerry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 200 ) Elsevier. Insert a soft-tipped catheter through the nares to suction secretions. This invasive technique may be used for a client who is unable to cough up a sputum specimen. To collect sputum for a cooperative client, have client take full inhalation followed immediately by a forceful cough, expectorating sputum directly into specimen containerPerry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 200 ) Elsevier. Use a hard-tipped Yankauer catheter device to remove oral secretions.Potter, P., Perry, A., Stockert, P., Hall, A. (2021). Fundamentals of Nursing (10th ed. pp. 922). Elsevier. This technique is primarily used to clear mucus secretions from the mouth of a client who is unable to cough to remove these secretions. To collect sputum have client take full inhalation followed immediately by a forceful cough, expectorating sputum directly into specimen container.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 200 ) Elsevier.

Section 5 Therapeutic Communication After the nurse repositions the finger clip, the oxygen saturation reading returns to 97%. Despite the normal reading, the client's mother appears worried and nervous and states that her child has never been sick and this scares her. To encourage the mother to share more about her feelings, how should the nurse respond? Your child will be just fine. You don't need to worry. I worried just like you when my child was sick. Perhaps you would rather wait outside. It sounds like this has been a very frightening experience for you.

It sounds like this has been a very frightening experience for you. Rationales: Your child will be just fine. You don't need to worry. This is patronizing and offers false reassurance.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 15 ) Elsevier. I worried just like you when my child was sick. This moves the conversation away from being client-centered and toward being nurse-centered.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 15) Elsevier. Perhaps you would rather wait outside. Though it may provide privacy, this will not encourage further communication.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. ) Elsevier. It sounds like this has been a very frightening experience for you. This open-ended statement acknowledges the difficult situation the mother is experiencing and encourages further discussion.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. ) Elsevier.

Which is the most important approach for the nurse to use when applying a nasal cannula? Ensure the cannula tubing stays snugly around the ears and under the chin. Make sure that the tip in the nasal prongs are aimed into the nares. Never allow the humidifier to run out of water. Keep some type of padding around the ears and over the cheekbones.

Make sure that the tip in the nasal prongs are aimed into the nares. Rationales: Ensure the cannula tubing stays snugly around the ears and under the chin. The cannula can be secured in this manner, but a snug fit is not the most important consideration.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 531) Elsevier. Make sure that the tip in the nasal prongs are aimed into the nares. This action directs the flow of oxygen into the client's upper respiratory tract.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 531) Elsevier. Never allow the humidifier to run out of water. Adequate humidification reduces the drying effect of the oxygen on the mucus membranes but is not the most important consideration.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 531) Elsevier. Keep some type of padding around the ears and over the cheekbones. Padding reduces the risk of pressure sores, but this is not the most important consideration.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 531) Elsevier. Submit Previous Section

Because of the client's dyspnea, the nurse is concerned that they may need to receive oxygen. Which action should the nurse perform that would be most indicative of the need for supplemental oxygen? Measure oxygen saturation. Auscultate breath sounds. Measure capillary refill. Observe chest expansion.

Measure oxygen saturation. Rationales: Measure oxygen saturation. Oxygen saturation provides important data about the percentage of hemoglobin that is saturated with oxygen, a valuable reflection of the client's overall oxygenation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 753) Elsevier. Auscultate breath sounds. Breath sounds does not measure oxygenation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 753) Elsevier. Measure capillary refill. Capillary refill is an indication of poor perfusion however does not measure oxygenation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 684) Elsevier. Observe chest expansion. The degree of chest expansion does not measure oxygenation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 99 ) Elsevier.

After receiving oxygen for a short while, the child is much less dyspneic. The nurse notes that the oxygen saturation reading is 97%. Fifteen minutes later, the oxygen saturation alarm indicates that the reading has changed to 80%. Which actions should the nurse implement immediately? (Select all that apply.) Select all that apply Observe the sensor to ensure it is intact and obtain another reading. Assess for signs and symptoms of respiratory distress. Encourage coughing and deep breathing. Increase the oxygen flow to 3 to 4 L/min. Notify the HCP immediately.

Observe the sensor to ensure it is intact and obtain another reading. Assess for signs and symptoms of respiratory distress. Encourage coughing and deep breathing. Rationales: Observe the sensor to ensure it is intact and obtain another reading. Since the child is not in any distress, the nurse should first reapply the clip and obtain another reading to confirm the sudden drop in oxygenation.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 104 ) Elsevier. Assess for signs and symptoms of respiratory distress. Assessment for signs and symptoms of respiratory distress is a priority.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 105) Elsevier. Encourage coughing and deep breathing. Coughing helps to clear mucus from the airway, which will allow for optimal lung expansion.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 105) Elsevier. Increase the oxygen flow to 3 to 4 L/min. This might be an important action to take, but not before assessing the client and other actions.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 105) Elsevier. Notify the HCP immediately. This will be important if the immediate actions taken by the nurse do not change the reading of the O2 saturation monitor.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 105) Elsevier.

Assessment Skills Section 1 The practical nurse (PN) evaluates the client's vital signs. Respirations are rapid and shallow. What technique should the nurse use to accurately evaluate the child's respirations? Observe chest expansion for 15 seconds and multiply by 4. Encourage the client to breathe as deeply and slowly as possible. Watch for nasal flaring and count the air exchanges with each movement. Place hands flat against the back or chest and observe the rise and fall of the chest.

Place hands flat against the back or chest and observe the rise and fall of the chest. Rationales: Observe chest expansion for 15 seconds and multiply by 4. Since the respirations are rapid and shallow, this technique will probably result in an inaccurate determination of respiratory rate.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 85) Elsevier. Encourage the client to breathe as deeply and slowly as possible. This will give false data about the client's respiratory rate.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 99 ) Elsevier. Watch for nasal flaring and count the air exchanges with each movement. Nasal flaring is a sign of respiratory distress and not a method of counting respirations.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 621) Elsevier. Place hands flat against the back or chest and observe the rise and fall of the chest. This technique allows the nurse to observe and count each ventilatory cycle, even when respirations are shallow. Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 99 ) Elsevier.

Section 10 Breath SoundsThe child is discharged home with prescriptions for the medication and is instructed to follow up with his HCP in a week. The child and his mother return to the HCP's office one week later, after completion of the course of antibiotic therapy. The nurse auscultates vesicular breath sounds in the peripheral lung fields. What action should the nurse take? Record the presence of clear breath sounds. Tell the client's mother that his lungs are still congested. Instruct the client to cough to clear his lungs and listen again. Notify the HCP of the abnormal lung sounds.

Record the presence of clear breath sounds. Rationales: Record the presence of clear breath sounds. Vesicular breath sounds are a normal finding in the peripheral lung fields.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 101 ) Elsevier. Tell the client's mother that his lungs are still congested. Vesicular lung sounds are clear.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 101 ) Elsevier. Instruct the client to cough to clear his lungs and listen again. Vesicular lung sounds are clear.Potter, P., Perry, A., Stockert, P., Hall, A. (2021). Fundamentals of Nursing (10th ed. pp. ). Elsevier. Notify the HCP of the abnormal lung sounds. Vesicular lung sounds are clear.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 101 ) Elsevier.

The mother of the client questions the nurse as to the purpose of an antitussive. The nurse explains that this medication should have what effect? Liquefy the respiratory secretions. Reduce the frequency of the cough. Decrease any pain with coughing. Prevent nausea due to the sputum.

Reduce the frequency of the cough. Rationales: Liquefy the respiratory secretions. The class of medication used to liquefy respiratory secretions is expectorantant. Antitussives are used to reduce the frequency of a cough. This may be desirable for the client at night, to allow him to sleep.Visovsky, C., Zambroski, C., Hosler, S. (2022). Introduction to clinical Pharmacology (10th ed. P. 115, 129 ). Elsevier. Reduce the frequency of the cough. Antitussives are used to reduce the frequency of a cough. This may be desirable for the client at night, to allow him to sleep.Visovsky, C., Zambroski, C., Hosler, S. (2022). Introduction to clinical Pharmacology (10th ed. P. 115, 129 ). Elsevier. Decrease any pain with coughing. Medications that reduce pain are analgesics. Antitussives are used to reduce the frequency of a cough. This may be desirable for the client at night, to allow him to sleep.Visovsky, C., Zambroski, C., Hosler, S. (2022). Introduction to clinical Pharmacology (10th ed. P. 115, 129 ). Elsevier. Prevent nausea due to the sputum. Medications that prevent nausea are antiemetics. Antitussives are used to reduce the frequency of a cough. This may be desirable for the client at night, to allow him to sleep.Visovsky, C., Zambroski, C., Hosler, S. (2022). Introduction to clinical Pharmacology (10th ed. P. 115, 129 ). Elsevier. Submit

Which assessment finding further supports diagnosis? Restlessness and dyspnea. Skin is warm and flushed. Complaints of being thirsty. Blood pressure of 102/62 mmHg.

Restlessness and dyspnea. Rationales: Restlessness and dyspnea. Restlessness and dyspnea are indications of hypoxia. Restlessness is an early sign of hypoxia that is often missed.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 654) Elsevier. Skin is warm and flushed. The client with impaired gas exchange will not manifest warm, flushed skin as a result of this problem. However, this may be a manifestation of an infection resulting in impaired gas exchange.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 654) Elsevier. Complaints of being thirsty. The client with impaired gas exchange will not manifest thirst as the result of this problem.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 654) Elsevier. Blood pressure of 102/62 mmHg. This is a normal blood pressure for a 9-year-old child. Normal BP ranges for children aged 6 to 12 years are 80 to 120 systolic and 45 to 70 diastolic.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 86) Elsevier.

Section 6 Ethical Considerations After further conversation with the client's mother, the nurse needs to leave the room to assess another client. Which action by the nurse demonstrates the use of trust in the nurse-client relationship? Teaching the child and his mother how to read the oximeter. Returning to the room at the time promised. Offering the mother reassurance that the child is stable. Providing a phone so that the child's mother can call home.

Returning to the room at the time promised. Rationales: Teaching the child and his mother how to read the oximeter. This demonstrates caring by the nurse and promotes client autonomy but is not an example of the concept of trust.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 14) Elsevier. Returning to the room at the time promised. Trust and rapport is important to develop during the orientation stage so the client has the most optimal outcome.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 14) Elsevier. Offering the mother reassurance that the child is stable. This action demonstrates caring and beneficence, but it is not an example of the concept of trust.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 14) Elsevier. Providing a phone so that the child's mother can call home. This action demonstrates caring and beneficence, but it is not an example of the concept of trust.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 14) Elsevier.

Section 7 Documentation Skills Upon returning to the room, the nurse hears and sees the child coughing. She assesses the cough further. Which documentation reflects subjective data? Respirations are 36 breaths/min. The client appears anxious by repeatedly reaching for his mother's hand and asking, if he is okay. The client's mother is present in the room. The client and his mother state he has a cough.

The client and his mother state he has a cough. Rationales: Which documentation reflects subjective data? Respirations are 36 breaths/min. This is objective data observed by the nurse.Potter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P.121) Elsevier. The client appears anxious by repeatedly reaching for his mother's hand and asking, if he is okay. This is objective data observed by the nurse. The nurse has observed that the client appears to be very anxious.Potter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P.121) Elsevier. The client's mother is present in the room. This is objective data observed by the nurse.Potter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P.121) Elsevier. The client and his mother state he has a cough. This is subjective as it is the client and his mother's reported symptom.Potter, P., Perry, A., Stockert, P. (2019). Essentials for Nursing Practice (9th ed. P.121) Elsevier.

Section 2 Pulse Oximetry The nurse plans to measure the child's oxygen saturation with a spring-tension finger clip. While the nurse is explaining this procedure, the client asks if it will hurt. Which response by the nurse is best? Yes, but the pain will only last a very short time. No, you will not even know the clip is on your finger. The clip feels like a clothespin squeezing your finger. You seem to be worried about experiencing pain.

The clip feels like a clothespin squeezing your finger. Rationales: Yes, but the pain will only last a very short time. It is important to be honest with children who will experience pain. However, the finger clip does not cause pain when applied.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 553 ) Elsevier. No, you will not even know the clip is on your finger. While it is correct that the finger clip is not painful, he will probably feel it on their finger.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 553) Elsevier. The clip feels like a clothespin squeezing your finger. This is an honest response to the child's question regarding pain and one that places the sensation they will feel in a context he can understand.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 553) Elsevier. You seem to be worried about experiencing pain. This is a therapeutic communication technique, but in this situation, it is most important to directly answer the client's question, rather than encourage further discussion about the possibility of pain.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 553) Elsevier.

When assisting with the planning of care for this client, the nurse's priority is focused toward what client goal? To maintain oxygen at 2 L/minute per nasal cannula. To monitor the child's oxygen saturation continuously. To maintain the child's oxygen saturation greater than 95% on room air. To ensure the child's respiratory function is stable.

To maintain the child's oxygen saturation greater than 95% on room air. Rationales: To maintain oxygen at 2 L/minute per nasal cannula. This is a nursing intervention rather than an outcome statement.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 529 ) Elsevier. To monitor the child's oxygen saturation continuously. This is a nursing intervention rather than an outcome statement.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 529 ) Elsevier. To maintain the child's oxygen saturation greater than 95% on room air. This client-centered outcome statement describes the desired outcome in measurable terms.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 529 ) Elsevier. To ensure the child's respiratory function is stable. This statement is broad and vague, and it does not provide a measurable outcome.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 529 ) Elsevier.

The child's mother further states that she is worried her 2-year-old daughter at home may also become ill. What is an appropriate and therapeutic response to the mother's concern about her daughter? If you breastfed your daughter, she will have natural immunity. She will be protected from illness if she has had all her scheduled vaccinations. There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms. She is young enough that she will not be as ill as her brother. There is nothing serious to worry about.

There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms. Rationales: If you breastfed your daughter, she will have natural immunity. Breastfeeding only provides temporary immunity in an infant. This statement can produce guilt or worry if the mother did not breastfeed.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 231) Elsevier. She will be protected from illness if she has had all her scheduled vaccinations. Vaccinations protect only from certain specific diseases, not all illnesses.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 152 ) Elsevier. There is a chance she may also become ill. Please call your pediatrician right away if she develops any symptoms. Viral infections can spread from person to person by droplets from sneezing or coughing and by direct contact. Colds are most contagious in the first two to three days after symptoms appear, so the sibling is at risk and the mother should be informed.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 148-149 ) Elsevier. She is young enough that she will not be as ill as her brother. There is nothing serious to worry about. This is patronizing and the nurse cannot know how ill the child might become.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 148-149 ) Elsevier.

The client's mother states that this is the third time in recent months she has brought her child to the ED with a cough and shortness of breath. The nurse asks the mother how many respiratory or other infections the child has had within the past year. What is the nurse's purpose for this question? To assess for suspected child neglect or abuse. To explore the possibility of antibiotic resistance developing. To assess for a possible immune deficiency disorder. To explore the need for a primary care provider to avoid ED visits.

To assess for a possible immune deficiency disorder. Rationales: To assess for suspected child neglect or abuse. Inquiring about the child's health history does not indicate that the nurse has concerns about neglect or abuse and is not relevant to this particular question. By 5 years of age a child should have developed immunity to many types of infections. It they continue to have reccurent infections it may be a sign of immune deficiency which will need further investigation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 68, 625 ) Elsevier. To explore the possibility of antibiotic resistance developing. Although the nurse asks the child's mother about history of infections in the past year, it is not necessarily inquiring because of concern over antibiotic resistance. By 5 years of age a child should have developed immunity to many types of infections. It they continue to have reccurent infections it may be a sign of immune deficiency which will need further investigation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 68, 625 ) Elsevier. To assess for a possible immune deficiency disorder. By 5 years of age a child should have developed immunity to many types of infections. It they continue to have reccurent infections it may be a sign of immune deficiency which will need further investigation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 68, 625) Elsevier. To explore the need for a primary care provider to avoid ED visits. The nurse should ask the mother if the child has a primary care provider to determine continuity of care however it is not directly related to the question. By 5 years of age a child should have developed immunity to many types of infections. It they continue to have recurrent infections it may be a sign of immune deficiency which will need further investigation.Hochenberry, Marilyn. (2022). Wong's Essentials of Pediatric Nursing (11th ed. P. 68, 625 ) Elsevier.

The client-care technician plans to transport the sputum specimen to the lab. Which instructions should the nurse provide? Wear clean gloves to carry the specimen to the lab. Wear clean gloves to place the specimen cup in a biohazard bag for transport. Wear gloves and a gown for the best protection. Wash hands after carrying the cup to the lab. Submit

Wear clean gloves to place the specimen cup in a biohazard bag for transport. Rationales: Wear clean gloves to carry the specimen to the lab. This is not the best protection for transporting body fluids. The correct way to handle a specimen is to wear clean gloves to place the specimen cup in a biohazard bag for transport.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 200 ) Elsevier. Wear clean gloves to place the specimen cup in a biohazard bag for transport. This protects the person transporting the specimen, as well as the lab personnel receiving the specimen.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 200 ) Elsevier. Wear gloves and a gown for the best protection. This is more protection than is needed. The correct way to handle a specimen is to wear clean gloves to place the specimen cup in a biohazard bag for transport.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 200 ) Elsevier. Wash hands after carrying the cup to the lab. This does not provide adequate protection during specimen transport. The correct way to handle a specimen is to wear clean gloves to place the specimen cup in a biohazard bag for transport.Perry, Potter, Ostendorf, Laplante. (2022). Clinical Nursing Skills and Techniques (10th ed. P. 200 ) Elsevier.

After assessing the client and verifying clear lung sounds and no cough, the HCP prescribes a CBC to completed. Which serum lab value confirms the resolution of infection? Red blood cell count (RBC) 4.5 x 106/mcL (4.5 x 1012/L). White blood cell count (WBC) 6000/mcL (6 x 109/L). Hemoglobin at 12 g/dL (120 g/L). Hematocrit at 40% (0.4 proportion of 1.0).

White blood cell count (WBC) 6000/mcL (6 x 109/L). Rationales: Red blood cell count (RBC) 4.5 x 106/mcL (4.5 x 1012/L). This is normal value for a child, but does not confirm resolution of the infection.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 805-807 ) Elsevier. White blood cell count (WBC) 6000/mcL (6 x 109/L). This is a normal value for a child, confirming the resolution of the infection. Infection generally causes an elevation in the WBC.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 805-807 ) Elsevier. Hemoglobin at 12 g/dL (120 g/L). This is a normal value for a child, but does not confirm resolution of infection. Part of (RBC) red blood cell.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 805-807 ) Elsevier. Hematocrit at 40% (0.4 proportion of 1.0). This is a normal value for a child, but does not confirm resolution of infection. Part of (RBC) red blood cell.Leifer, Gloria. (2019). Introduction to Maternity and Pediatric Nursing (8th ed. P. 805-807 ) Elsevier.