a 3 year old female presents with respiratory distress she is conscious crying and clinging to her mother she has mild intercostal retractions and an
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Nursing Elites

ATI LPN

LPN Pediatrics

1. A 3-year-old female presents with respiratory distress. She is conscious, crying, and clinging to her mother. She has mild intercostal retractions and an oxygen saturation of 93%. The MOST effective way of delivering oxygen to her involves:

Correct answer: C

Rationale: In a pediatric patient with respiratory distress, a non-rebreathing mask with a flow rate set at 6 to 8 L/min is the most effective way to deliver oxygen. This method ensures a high concentration of oxygen is delivered to the child, aiding in improving oxygen saturation levels. In this scenario, the mother can assist in holding the mask to maintain comfort and cooperation in the child while ensuring proper oxygen delivery.

2. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

Correct answer: B

Rationale: The most appropriate nursing diagnosis for the 18-month-old child presenting with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm is 'Ineffective breathing pattern.' These symptoms collectively indicate respiratory distress, which aligns with the nursing diagnosis of ineffective breathing pattern. Nasal flaring, intercostal retractions, and an increased respiratory rate are signs of respiratory distress in pediatric patients, suggesting the need for immediate intervention to address the underlying breathing difficulties.

3. What should the nurse include in the insulin administration instruction for the parents of a child being discharged on insulin?

Correct answer: C

Rationale: The correct answer is C because the muscles in the abdomen and thigh are the most suitable areas for self-administration of insulin due to consistent absorption. Choices A and B are incorrect as aspirating before injecting insulin is unnecessary, and injecting into an extremity to be exercised does not enhance absorption. Choice D is incorrect as alcohol should be used to clean the injection site instead of soap and water, which can cause skin irritation.

4. What is the appropriate treatment for a responsive 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color?

Correct answer: D

Rationale: For a responsive 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color, the appropriate treatment includes providing supplemental oxygen and arranging for transport to a healthcare facility. Oxygen helps alleviate the respiratory distress, and transport ensures the child receives further evaluation and care by healthcare professionals. Back slaps and subdiaphragmatic thrusts are not recommended for a child with a mild airway obstruction and normal skin color, as these interventions are typically reserved for more severe cases of airway obstruction.

5. An infant with congestive heart failure is receiving diuretic therapy. A nurse is closely monitoring the intake and output. The nurse uses which most appropriate method to assess the urine output?

Correct answer: A

Rationale: Weighing the diapers is the most appropriate method to assess urine output in infants. Diapers will absorb and retain urine, providing a measurable indicator of urine output without invasive procedures. This method is non-invasive, simple, and convenient for monitoring urine output, especially in infants who may not be able to use other urine output measurement techniques. Inserting a Foley catheter is invasive and not indicated for routine urine output monitoring in infants. Comparing intake with output does not directly measure urine output. Measuring the amount of water added to formula does not provide an accurate assessment of urine output.

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