During a respiratory assessment, the nurse notes a sinking in of soft tissues relative to the cartilaginous and bony thorax. What is the term for this finding?
a. Grunting
b. Tachypnea
c. Retractions
d. Nasal flaring
ANS: C
Retractions are defined as the sinking of soft tissue relative to the cartilaginous or bony thorax. Retractions can be extreme in severe airway obstruction as the work of breathing increases. Grunting can be a sign of pain in older children with respiratory issues. It serves to increase the end-respiratory pressure, which prolongs the period of oxygen and carbon dioxide exchange across the membrane. Tachypnea is an increase in the respiratory rate above the child's baseline. Nasal flaring, the enlargement of the nostrils, helps reduce nasal resistance and maintains airway patency.
You might also like to view...
When the nurse reviews the effectiveness of the client's lithium level, the nurse should take into account which of the following client factors?
1. Marital status 2. Gender 3. Ethnicity 4. Weight
The nurse manager is discussing cultural considerations with a group of staff nurses. Which statements by the staff nurses indicate an appropriate understanding of cultural concepts?
Select all that apply. 1. "Culture can best be described as an awareness of belonging to a group in which certain characteristics differentiate the members of one group from another." 2. "A good description of culture is one that recognizes it's the socially transmitted beliefs, behaviors, values, customs, lifestyles, and ways of thinking of a specific population that guides an individual's worldview." 3. "Culture is the belief that one's own beliefs, way of life, values, and customs are superior to others." 4. "Culture is the identification of an individual or group by shared genetic heritage and biologic characteristics." 5. "Decisions made by an individual are largely influenced by culture."
A nurse is caring for a client with congestive heart failure. The healthcare provider prescribes propranolol (Inderal) for the client. Which instruction should the nurse include when administering a beta-adrenergic like propranolol (Inderal) to the client
A) "This medication must be taken on an empty stomach." B) "You will need to discontinue the medication when your symptoms subside." C) "This medication causes constipation. You should take a laxative every day." D) "It is important to notify the healthcare provider if you experience urinary retention."
The staff development trainer is preparing a seminar to review the concepts of a just culture, which is being implemented in the organization. Which elements are integral when training on this content? Select all that apply
A) Managers providing feedback to staff regarding actions B) Proactive environment that supports employee involvement in decision making C) Supports learning D) Examines system failures when an adverse event occurs E) Nurse accountability for actions