A 6-month-old child presented to the Emergency Department with tachypnea, marked retractions, listlessness, and poor eating and drinking. Nasal swab was positive for respiratory syncytial virus (RSV) and she was just admitted to the hospital with the diagnosis of RSV bronchiolitis. What nursing interventions would be most appropriate, assuming you have a physician's order?
Administer Synagis® immediately and encourage fluids by mouth.
Administer antiviral medication, limit fluids and give antitussives.
Encourage fluids by mouth, IV antibiotics, and oxygen mist therapy.
Provide oxygen mist therapy, administer IV fluids, and hand washing.
The Correct Answer is D
Choice A reason: This is not the correct answer because Synagis® is a monoclonal antibody that is given as a prophylaxis to prevent severe RSV infection in high-risk infants. It is not effective as a treatment for RSV bronchiolitis.
Choice B reason: This is not the correct answer because antiviral medication is not routinely recommended for RSV bronchiolitis, as it has not been shown to improve outcomes. Limiting fluids and giving antitussives may also be harmful, as they can cause dehydration and suppress the cough reflex.
Choice C reason: This is not the correct answer because IV antibiotics are not indicated for RSV bronchiolitis, which is a viral infection. Antibiotics may increase the risk of antibiotic resistance and adverse effects.
Choice D reason: This is the correct answer because oxygen mist therapy can help humidify the air and relieve the respiratory distress. IV fluids can prevent dehydration and maintain electrolyte balance. Hand washing can prevent the spread of RSV infection to other patients and staff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement is true because children, especially young children, may have difficulty expressing their pain or may be ignored by health care providers who underestimate their pain. Therefore, they may not receive adequate pain relief.
Choice B reason: This statement is false because children experience pain with procedures just as much as adults, if not more. Children may have more fear and anxiety associated with pain, which can amplify their perception of pain.
Choice C reason: This statement is false because infants experience pain as much as older children and adults. Infants have a fully developed nervous system that can sense and respond to pain stimuli. Infants may also have more long-term effects of pain, such as altered pain sensitivity and behavioral problems.
Choice D reason: This statement is false because children have a very low risk of becoming addicted to narcotics when they are used appropriately for pain management. Addiction is a psychological phenomenon that involves craving and compulsive use of a substance, which is rare in children who receive narcotics for pain relief.
Correct Answer is A
Explanation
Choice A reason: This is the most comprehensive and accurate way of assessing a child's pain, as it takes into account the child's own perception, the parent's observation, and the objective signs of pain.
Choice B reason: This is not the best approach, as the parents may not be able to accurately rate the child's pain, especially if the child is too young or has communication difficulties.
Choice C reason: This is not the best approach, as behavioral clues may not always reflect the intensity or quality of pain, and may be influenced by other factors such as fear, anxiety, or coping strategies.
Choice D reason: This is not the best approach, as physiological measures may not always correlate with pain, and may be affected by other variables such as medication, stress, or illness.
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