Author Question: The nurse is providing care to an infant in the emergency department (ED). Initial assessment ... (Read 101 times)

gbarreiro · **on:** Jun 25, 2018

The nurse is providing care to an infant in the emergency department (ED). Initial assessment indicates that the infant is experiencing an asthma attack.

The infant is unresponsive to medication and a chest x-ray reveals a foreign body partially obstructing the airway. While placing an oxygen mask on the infant, the nurse notes a total obstruction of the airway. Which nursing action is appropriate?
A) Attempt to clear the obstruction by delivering back blows and chest thrusts.
B) Attempt to clear the obstruction by delivering back blows.
C) Attempt to clear the obstruction by delivering back blows and abdominal thrusts.
D) Attempt to clear the obstruction by delivering abdominal thrusts.

Question 2

The nurse working on a pediatric unit is caring for a client newly diagnosed with asthma. Which assessment data indicates exhaustion and the need for immediate intervention?

Select all that apply.
A) Shallow respirations
B) Slightly diminished breath sounds
C) Decreased wheezing
D) Increased crackles
E) Increased respiratory rate

bubulittle310@msn.cn · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: A

When a life-threatening total airway obstruction occurs, efforts to clear the obstruction include back blows and chest thrusts in an infant; therefore, the appropriate action for the nurse to take is to deliver back blows and chest thrusts. Abdominal thrusts are appropriate in older children.

Answer to Question 2

Answer: A, C

Respiratory status can change rapidly during an acute asthma attack. Slowed, shallow respirations with significantly diminished breath sounds and decreased wheezing may indicate exhaustion and impending respiratory failure. Immediate intervention is necessary. Increased crackles are usually associated with heart failure and are not an indication of exhaustion. An increased respiratory rate indicates respiratory compromise, but not exhaustion.