Free NCLEX Practice Questions.
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- Question 1 of 1
A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following?Correct
Answer & Rationale:
Option 4 is Correct
Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.Incorrect
Answer & Rationale:
Option 4 is Correct
Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
- Bacterial form of croup
- Inflammation of the epiglottis occurs, which may be caused by Haemophilus influenzae type b or Streptococcus pneumoniae; children immunized with H. influenzae type b (Hib vaccine) are at less risk for epiglottitis.
- Occurs most frequently in children 2 to 8 years old, but can occur from infancy to adulthood
- Onset is abrupt, and the condition occurs most often in the winter.
- Considered an emergency situation because it can progress rapidly to severe respiratory distress
- High fever
- Sore, red, and inflamed throat (large, cherry red, edematous epiglottis) and pain on swallowing
- Absence of spontaneous cough
- Muffled voice
- Retractions and child struggles to breathe
- Inspiratory stridor aggravated by the supine position
- Tachypnea progressing to more severe respiratory distress (hypoxia, hypercapnia, respiratory acidosis, decreased level of consciousness)
- Tripod positioning: While supporting the body with the hands, the child leans forward, thrusts the chin forward and opens the mouth in an attempt to widen the airway
- Maintain a patent airway.
- Assess respiratory status and breath sounds, noting nasal flaring, the use of accessory muscles, retractions, and the presence of stridor.
- Assess temperature by the axillary route, not the oral route.
- Monitor pulse oximetry.
- Prepare the child for lateral neck films to confirm the diagnosis (accompany the child to the radiology department).
- Maintain NPO status.
- Do not leave the child unattended.
- Avoid placing the child in a supine position because this position would affect the respiratory
- status further.
- Do not restrain the child or take any other measure that may agitate the child.
- Administer intravenous fluids as prescribed; insertion of an intravenous line may need to be delayed until an adequate airway is established because this procedure may agitate the child.
- Administer intravenous antibiotics as prescribed; these are usually followed by oral antibiotics.
- Administer analgesics and antipyretics (acetaminophen [Tylenol] or ibuprofen [Motrin]) to reduce fever and throat pain as prescribed.
- Administer corticosteroids to decrease inflammation and reduce throat edema as prescribed.
- Nebulized epinephrine (racemic epinephrine) may be prescribed for severe cases (causes mucosal vasoconstriction and reduces edema); heliox (mixture of helium and oxygen) may also be prescribed to reduce mucosal edema.
- Provide cool mist oxygen therapy as prescribed; high humidification cools the airway and decreases swelling.
- Have resuscitation equipment available, and prepare for endotracheal intubation or tracheotomy for severe respiratory distress.
- Ensure that the child is up to date with immunizations, including Hib conjugate