A nurse is assisting an infant who has respiratory syncytial virus.
For which of the following findings should the nurse intervene?
Brisk capillary refill
Tachypnea
Rhinorrhea
Coughing
The Correct Answer is B
Choice A rationale
Brisk capillary refill is a normal finding and does not require intervention.
Choice B rationale
Tachypnea, or rapid breathing, is a common symptom of respiratory syncytial virus (RSV) infection in infants. It can indicate that the infant is having difficulty breathing and needs immediate intervention.
Choice C rationale
Rhinorrhea, or a runny nose, is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
Choice D rationale
Coughing is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A creatinine level of 1.4 mg/dL is higher than the normal range and could indicate kidney damage, which is a known side effect of gentamicin. Therefore, the nurse should notify the healthcare provider.
Choice B rationale
A creatinine level of 0.3 mg/dL is within the normal range, so it would not typically be a cause for concern.
Choice C rationale
A BUN level of 12 is within the normal range, so it would not typically be a cause for concern.
Choice D rationale
A BUN level of 6 is within the normal range, so it would not typically be a cause for concern.
Correct Answer is B
Explanation
When prioritizing care for multiple clients, the nurse should first assess the client who is most unstable and has the most urgent needs. In this case, the adolescent with sickle cell anemia and slurred speech should be assessed first. Slurred speech could indicate a stroke, which is a life-threatening condition that requires immediate medical attention. The other clients, while they also require care, are not in immediate danger and can be assessed after the adolescent with sickle cell anemia.
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