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","C","E"]
Explanation
Choice A rationale
Providing a high-calorie diet is a recommended action for a child who has received partial-thickness burns to
over 50% of his body. After a burn injury, the body needs extra calories and protein to heal, fight infection, and maintain its functions. A high-calorie diet can help meet these increased nutritional needs.
Choice B rationale
Administering analgesics intramuscularly (IM) is not a recommended action for a child with partial- thickness burns. Pain management is crucial in burn care, but analgesics should be given orally or intravenously, not IM, to avoid additional pain and tissue damage.
Choice C rationale
Monitoring intake and output is a recommended action for a child who has received partial-thickness burns to over 50% of his body. This can help assess the child’s hydration status, kidney function, and response to fluid replacement therapy.
Choice D rationale
Removing splints during sleep is not a recommended action for a child with partial-thickness burns. Splints are used to prevent contractures by keeping the joints in a functional position. They should be worn as prescribed by the healthcare provider, which often includes during sleep.
Choice E rationale
Changing dressings using aseptic technique is a recommended action for a child who has received partial- thickness burns to over 50% of his body. This can help prevent infection, promote healing, and assess the burn’s progress.
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.
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