Difficulty: Medium
Average Score: 63%
Simulated
Passage / Scenario
Vital Signs (0700 hrs): Temperature: 39°C (102.2°F), Heart rate: 148/min, Respiratory rate: 42/min, Blood pressure: 87/44 mm Hg, SpO2: 89% on room air. Nurse's Notes (0700 hrs): The toddler presents with a high fever, cough, and difficulty breathing. The mother reports that the child has been irritable and not eating well for the past two days. The child is observed to have nasal flaring and intercostal retractions. Breath sounds are diminished with wheezing heard bilaterally. The child is restless and crying intermittently. The mother denies any known allergies or recent travel. The child has a history of frequent upper respiratory infections. Diagnostic Results (0700 hrs): Rapid RSV antibody test: Positive (per nasal swab), Blood culture: Pending, Hgb: 10 g/dL, Hct: 40%, WBC: 10,000/mm³, Platelets: 230,000/mm³, Glucose: 82 mg/dL, BUN: 18 mg/dL. Medication Administration Record (0700 hrs): Albuterol 2.5 mg via nebulizer now. May repeat every 20 min for 1 hr as needed for wheezing and retractions. Oxygen 2 L/min via nasal cannula.Which of the following findings should the nurse identify as an indication that the treatment plan is effective? (Select all that apply.)
Correct answer
C,D,E
Rationale
The correct answers are C, D, and E.
C: Oxygen saturation indicates how well the patient is oxygenating. An increase in oxygen saturation signifies improved oxygen levels, indicating treatment effectiveness.
D: Clear breath sounds in bilateral bases suggest proper airflow in the lungs, indicating treatment success.
E: A decrease in respiratory rate indicates that the patient is breathing more comfortably due to treatment efficacy.
Incorrect choices:
A: Nasal flaring and B: Retractions are signs of respiratory distress and would suggest that the treatment plan is not effective.
F: Heart rate alone does not directly indicate respiratory treatment effectiveness.
In summary, the correct choices directly reflect improvements in oxygenation, lung function, and respiratory effort, while the incorrect choices signify respiratory distress or are not specific indicators of respiratory treatment effectiveness.
C: Oxygen saturation indicates how well the patient is oxygenating. An increase in oxygen saturation signifies improved oxygen levels, indicating treatment effectiveness.
D: Clear breath sounds in bilateral bases suggest proper airflow in the lungs, indicating treatment success.
E: A decrease in respiratory rate indicates that the patient is breathing more comfortably due to treatment efficacy.
Incorrect choices:
A: Nasal flaring and B: Retractions are signs of respiratory distress and would suggest that the treatment plan is not effective.
F: Heart rate alone does not directly indicate respiratory treatment effectiveness.
In summary, the correct choices directly reflect improvements in oxygenation, lung function, and respiratory effort, while the incorrect choices signify respiratory distress or are not specific indicators of respiratory treatment effectiveness.