A client’s child has been diagnosed with RSV.
The client is concerned about the risk of dehydration for their child.
The nurse reassures the client by saying which of the following?
“We will encourage oral fluids or provide intravenous fluids as prescribed to prevent dehydration.”.
“Your child will need to drink at least 8 glasses of water a day.”.
“We will limit your child’s fluid intake to prevent overhydration.”.
“Your child should only drink clear liquids until their condition improves.”..
The Correct Answer is A
Choice A rationale:
This is The correct answer because it addresses the client's concern about dehydration.
Infants and young children with RSV infection are at risk of dehydration due to increased respiratory effort, fever, and decreased oral intake.
Encouraging oral fluids or providing intravenous fluids as prescribed helps prevent dehydration, ensuring the child remains hydrated during the illness.
Choice B rationale:
While adequate fluid intake is essential, stating a specific quantity like 8 glasses of water a day is not appropriate for infants and young children.
The fluid requirements vary based on the child's age, weight, and overall health condition.
Providing a specific quantity without proper assessment can be misleading and may not meet the child's individual needs.
Choice C rationale:
Limiting the child's fluid intake to prevent overhydration is not the primary concern in this context.
Dehydration due to increased respiratory effort and decreased oral intake is a more significant concern.
Adequate hydration is crucial in preventing complications associated with dehydration.
Choice D rationale:
Restricting the child to clear liquids only is not appropriate, especially in the context of RSV infection.
While clear liquids are essential, they may not provide adequate nutrition.
Maintaining appropriate oral intake, which includes a variety of fluids and, if possible, nutritionally balanced foods, is important for the child's overall well-being during the illness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Administering bronchodilators as prescribed is appropriate for managing severe respiratory distress and wheezing in children with RSV infection.
Bronchodilators help dilate the airways, making it easier for the child to breathe.
This intervention addresses one of the specific symptoms mentioned in the scenario.
Choice B rationale:
Encouraging fluid intake is important to prevent dehydration, especially in children with respiratory infections.
It helps maintain hydration status, which is essential for overall health.
While important, this choice alone does not address the severe respiratory distress symptoms mentioned in the scenario.
Choice C rationale:
Monitoring oxygen saturation levels is crucial in children with RSV infection, especially when they exhibit symptoms of severe respiratory distress such as wheezing, retractions, nasal flaring, tachypnea, and cyanosis.
Monitoring oxygen saturation helps assess the child's oxygenation status and guides interventions such as oxygen therapy.
Choice D rationale:
The correct answer is choice D, “All of these.”.
This is because all the interventions mentioned in choices A, B, and C are appropriate and necessary for managing severe respiratory distress in a toddler with RSV infection.
Administering bronchodilators addresses airway constriction and wheezing, encouraging fluid intake prevents dehydration, and monitoring oxygen saturation levels ensures appropriate oxygenation, allowing comprehensive care for the child’s condition.
Correct Answer is ["A","C"]
Explanation
Choice A rationale: The child’s respiratory rate of 35 breaths per minute is slightly elevated but not uncommon for a 3-year-old with a respiratory infection like RSV. Given the child's oxygen saturation is 96%, which is within normal range, it is appropriate to continue monitoring the respiratory rate. Monitoring ensures any changes in the child’s condition can be promptly addressed without unnecessary interventions.
Choice B rationale: Administering supplemental oxygen is not necessary in this case because the child’s oxygen saturation is 96%, which is within the normal range (95-100%). Providing supplemental oxygen without clinical indication can cause potential harm and is not warranted when oxygen levels are adequate.
Choice C rationale: Reassessing the child’s oxygen saturation in one hour is a prudent action. This allows the nurse to ensure that the child’s oxygen levels remain stable and to detect any potential decline in respiratory function. It provides an ongoing assessment to ensure the child's condition does not worsen.
Choice D rationale: The pH value of 7.38 is within the normal range (7.35-7.45), indicating that the child is not experiencing acid-base imbalance. There is no immediate need to notify the healthcare provider about the pH value alone, as it does not suggest any critical condition requiring urgent intervention.
Choice E rationale: Preparing for immediate intubation due to elevated PaCO2 is not warranted. The child’s PaCO2 is 40, which is within the normal range for carbon dioxide levels (35-45 mmHg). Intubation is a severe intervention reserved for cases of respiratory failure, which is not indicated by the presented lab results.
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