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.

Answer and Explanation

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.

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Correct Answer is ["A","B"]

Explanation

Choice A reason: This response is correct because antibiotics are indicated for bacterial pneumonia caused by staphylococcus. Antibiotics help to fight the infection and prevent complications.

Choice B reason: This response is correct because cluster care means grouping nursing interventions together to minimize the disruption of the child's rest and sleep. Cluster care helps to conserve the child's energy and promote healing.

Choice C reason: This response is not correct because fluids are essential for hydration and thinning of secretions in pneumonia. Fluids help to prevent dehydration and facilitate expectoration of mucus.

Choice D reason: This response is not correct because antitussive agents are not recommended for pneumonia. Antitussive agents suppress the cough reflex, which is a natural mechanism to clear the airways of secretions. Antitussive agents may increase the risk of respiratory infection and atelectasis.

A. Stridor B. Wheezes C. Crackles D. Rhonchi

Correct Answer is A

Explanation

Choice A reason: Stridor is a high-pitched, harsh sound that occurs during inspiration. It is caused by the narrowing of the upper airway due to inflammation and edema. Stridor is a characteristic sign of croup, also known as laryngotracheobronchitis.

Choice B reason: Wheezes are high-pitched, musical sounds that occur during expiration. They are caused by the narrowing of the lower airway due to bronchoconstriction or mucus. Wheezes are more common in asthma than in croup.

Choice C reason: Crackles are fine, crackling sounds that occur during inspiration. They are caused by the opening of collapsed or fluid-filled alveoli. Crackles are more common in pneumonia or heart failure than in croup.

Choice D reason: Rhonchi are low-pitched, snoring sounds that occur during expiration. They are caused by the vibration of mucus in the large airways. Rhonchi are more common in bronchitis or cystic fibrosis than in croup.

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Naxlex Comprehensive Predictor Exams

An infant has developed staphylococcal pneumonia. Nursing care of the child with pneumonia includes which of the following? (Select all that apply).

Correct Answer is ["A","B"]

Explanation

The parent of a toddler calls the nurse, asking about croup. What is a distinguishing manifestation of croup?

Correct Answer is A

Explanation

The parent of a toddler calls the nurse, asking about croup. What is a distinguishing manifestation of croup?

Staff members working with school-aged children believe it is important for each child to understand and agree to medical treatment, especially when treatment is part of research protocols. The term for this process is:

When obtaining a history from parents of a 4-year-old child, what indicator should prompt the nurse to consider suspected child abuse?

When assessing a child's pain, the best approach is for the nurse to:

Shortly before a child's elective surgery, the parent tells the nurse, "I am having second thoughts about my child undergoing this surgery." The nurse respects the parent's concern and calls the surgeon. What ethical/moral principle is represented by this situation?

An 8-year-old child, who has a history of asthma, is seen in the office of the school nurse with coughing and wheezing. Which of the following actions should the nurse perform first?

A 15-month-old toddler is admitted with pneumonia and is started on PO Amoxicillin. The child weighs 11 kg. The safe dose range is 20-40 mg/kg/day. Which dose is safe?

A six-year-old girl is brought to the emergency department. She has a "frog-like croaking sound" on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should first do which of the following?