A 3-year-old with croup has the following vital signs: HR 90, RR 44, BP 100/52, T 98.8°F. The parents ask if these are normal. The nurse's best response is:

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Question 1 of 5

A 3-year-old with croup has the following vital signs: HR 90, RR 44, BP 100/52, T 98.8°F. The parents ask if these are normal. The nurse's best response is:

Correct Answer: C

Rationale: The elevated respiratory rate is concerning since normal for a 3- to 6-year-old is about 20-30 breaths per minute.

Question 2 of 5

Two hours after arriving on the medical-surgical unit, the client develops dyspnea. SaO2 is 91%, and the client is exhibiting audible wheezing and use of accessory muscles. Which of the following medications should the nurse expect to administer?

Correct Answer: D

Rationale: In this situation, the client is experiencing dyspnea, audible wheezing, and decreased oxygen saturation, indicating the presence of respiratory distress, likely due to bronchoconstriction. These are classic symptoms of an acute asthma exacerbation or an obstructive respiratory condition. Beta2 agonists, such as albuterol, are bronchodilators that work by relaxing the muscles in the airways, relieving bronchoconstriction and improving airflow. Administering a beta2 agonist promptly is crucial to provide relief and improve the client's respiratory status. Antibiotics, antivirals, and beta-blockers are not appropriate treatments for acute bronchoconstriction or asthma exacerbation.

Question 3 of 5

The MOST likely cause of a 4-year-old boy refusing to go to bed and remaining active is

Correct Answer: C

Rationale: Behavioral insomnia involves resistance to bedtime routines.

Question 4 of 5

The basic principle of healthy sleep hygiene which is NOT included is

Correct Answer: D

Rationale: Heavy meals close to bedtime disrupt sleep.

Question 5 of 5

A parent of a child with glomerulonephritis asks why the urine is discolored. Which is the best response?

Correct Answer: B

Rationale: Hematuria (blood in the urine) is a common finding in glomerulonephritis and causes a tea-colored appearance.

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