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
The correct answer is choice a. Discourage the child from coughing.
Choice A rationale:
Discouraging the child from coughing is important because coughing can dislodge clots and cause bleeding at the surgical site, which is a common complication after a tonsillectomy.
Choice B rationale:
Providing cranberry juice to the child is not recommended because acidic juices can irritate the throat and cause discomfort or pain.
Choice C rationale:
Maintaining the child in a supine position is not ideal as it can increase the risk of aspiration. Instead, the child should be positioned on their side or with the head elevated to facilitate drainage and reduce the risk of aspiration.
Choice D rationale:
Administering an analgesic to the child on a scheduled basis is important for pain management, but it is not the most immediate action to take one hour postoperatively. Pain management should be part of the overall care plan.
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason: A White Blood Cell (WBC) count of 20,000/mm³ is significantly higher than the normal range for children, which is typically between 5,000 to 10,000/mm³. In the context of acute lymphoblastic leukemia (ALL), a high WBC count could indicate an active disease process or a reaction to treatment, rather than a therapeutic effect.
Choice B reason: A hemoglobin level of 5.5 g/dL is quite low, as the normal range for children is generally between 11 to 16 g/dL. This level of hemoglobin suggests anemia, which is a common condition in patients with leukemia due to the disease itself or as a side effect of chemotherapy. It does not necessarily indicate that the treatment is having a therapeutic effect.
Choice C reason: A Platelet count of 150,000/mm³ is within the lower end of the normal range for children, which is approximately 150,000 to 450,000/mm³. This can be considered a sign that the treatment is working effectively, as it indicates bone marrow recovery and the production of platelets is returning to normal levels.
Choice D reason: A Red Blood Cell (RBC) count of 3/mm³ is extremely low. The normal range for children’s RBC count is about 4 million to 5.5 million/mm³. Such a low RBC count would indicate severe anemia and is not a sign of effective treatment for ALL.
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