During a respiratory assessment, the nurse notes that the patient is breathing with the use of accessory muscles. What does this finding suggest?

Correct Answer: B

Rationale: The correct answer is B, respiratory distress. When a patient is using accessory muscles to breathe, it indicates increased effort to maintain adequate ventilation, a hallmark of respiratory distress. This can be due to various conditions such as asthma, pneumonia, or acute respiratory distress syndrome. Accessory muscle use is a compensatory mechanism to help increase airflow in the presence of respiratory compromise. Choices A, C, and D are incorrect because the use of accessory muscles is not indicative of a normal breathing pattern, pulmonary embolism, or COPD specifically. It is important to recognize and address respiratory distress promptly to prevent further complications.

Correct Answer: A

Rationale: RN (Registered Nurse), is correct because upon admission, a comprehensive assessment, including vital signs, is typically performed by an RN due to their advanced training and scope of practice. RNs interpret data, identify abnormalities, and develop care plans, making them the most appropriate initial evaluator. LPN (Licensed Practical Nurse), assists with care but often works under RN supervision with a narrower scope. PCT (Patient Care Technician), and CNA (Certified Nursing Assistant), perform basic tasks like taking vital signs but lack the RNs authority to assess and act on findings independently upon admission. Hospital protocols prioritize RNs for initial assessments to ensure accuracy and timely intervention, especially in critical cases. Thus, A is the best choice, reflecting professional standards and patient safety priorities.

Correct Answer: D

Rationale: Normal vital signs vary by age. For a 4-month-old, a temperature of 38.1°C (100.5°F) is within the normal range of 37.1°C to 38.1°C (98.7°F to 100.5°F), making A correct. A 3-year-olds normal blood pressure is around 89/46 mmHg; 118/80 is elevated, so B is incorrect. A 9-year-olds temperature of 39°C (102.2°F) exceeds the normal range of 36.8°C to 37.8°C (98.2°F to 100°F), so C is incorrect. An adolescents pulse of 70 beats/min fits the normal range of 55 to 105, making D correct. Adults have a respiratory rate of 12 to 20 breaths/min, and older adults have a pulse of 40 to 100 beats/min, but these arent options here. Since this is a multiple-choice question with one answer listed as correct, D is the focus, supported by its alignment with age-specific norms.

Correct Answer: A

Rationale: Cooling blankets manage fever effectively with proper use. Positioning with the top edge at the neck ensures full-body coverage, maximizing cooling, making it correct. A rectal probe for comatose patients is accurate but context-specific. Covering with a thick blanket insulates, counteracting cooling. Avoiding lanolin prevents interference but isn't a primary guideline. Choice A is best as it addresses placement, a fundamental step in hypothermia blanket protocols, ensuring efficient heat exchange per nursing standards.

Correct Answer: B

Rationale: In infants, the brachial artery is preferred for pulse due to accessibility and strength; radial is weak and hard to palpate. Femoral and popliteal are less practical. Choice B is correct, per pediatric norms, ensuring accurate infant pulse assessment.