A nurse is assisting in the care of an 8-month-old infant in the pediatric unit.
Complete the diagram by dragging from the choices below to specify what condition the infant is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the infant's progress.
The Correct Answer is []
Condition: Viral Upper Respiratory Infection (URI).
2 actions:
- Administer saline nasal drops,
- Encourage oral hydration.
2 parameters:
- Respiratory rate,
- Oxygen saturation.
Rationale for correct condition: A viral upper respiratory infection (URI) is indicated by the infant's symptoms of nasal congestion, cough, and mild intercostal retractions. The clear breath sounds suggest the absence of lower respiratory tract infection. The fever and irritability are consistent with a viral infection. The normal oxygen saturation level supports a less severe respiratory condition. The history of reduced feeding aligns with the discomfort caused by nasal congestion.
Rationale for actions: Administering saline nasal drops helps to relieve nasal congestion, improving the infant's breathing and comfort. Saline is safe and effective for clearing nasal passages in infants. Encouraging oral hydration ensures the infant remains well-hydrated, which is crucial for overall health and recovery. Adequate hydration helps thin mucus secretions, making it easier for the infant to breathe. Administering nebulized albuterol is more appropriate for bronchiolitis or asthma. Obtaining a chest X-ray is unnecessary without signs of pneumonia. Starting supplemental oxygen is not indicated with normal oxygen saturation.
Rationale for parameters: Monitoring respiratory rate helps assess the infant's breathing pattern and detect any signs of respiratory distress. Changes in respiratory rate can indicate worsening or improvement of the condition. Oxygen saturation monitoring ensures the infant maintains adequate oxygen levels, crucial for identifying any need for supplemental oxygen. Serum electrolyte levels are not directly related to a URI. Capillary refill time is important but not specific to respiratory conditions. Urine output monitors hydration but is less specific for respiratory assessment.
Rationale for incorrect conditions: Bronchiolitis presents with more severe respiratory distress and wheezing. Pneumonia would show abnormal lung sounds and possibly a higher fever. Foreign body aspiration would cause sudden onset of symptoms and possibly localized wheezing or stridor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Massaging the injection site after administering a vaccine is generally not recommended as it may cause irritation or introduce bacteria to the site, increasing the risk of infection. Additionally, massaging the area does not improve the absorption or efficacy of the vaccine. Vaccines are designed to be absorbed effectively by the body without the need for additional manipulation. Healthcare professionals are trained to administer vaccines using techniques that minimize discomfort and ensure proper delivery of the vaccine into the muscle tissue.
Choice B rationale
Aspiration, or pulling back on the syringe plunger after inserting the needle but before injecting the vaccine, is not recommended when administering vaccines. Studies have shown that aspiration is unnecessary and may increase the risk of injury, pain, and prolonged injection time. The practice of aspiration is based on the outdated concern of inadvertently injecting the vaccine into a blood vessel. However, research indicates that the risk of this occurring is extremely low when proper injection techniques are used. The focus should be on delivering the vaccine quickly and efficiently to minimize discomfort.
Choice C rationale
Ensuring that the guardian has signed a consent form for immunization is an essential step in the vaccination process. Obtaining informed consent means that the guardian is aware of the potential benefits and risks associated with the vaccine and agrees to proceed with the vaccination. This practice is crucial for maintaining trust between healthcare providers and patients, respecting the rights of individuals to make informed healthcare decisions, and adhering to legal and ethical standards in medical practice. Proper documentation of consent is also important for record-keeping and future reference.
Correct Answer is D
Explanation
Choice A rationale
Decreased pressure in the cerebrospinal fluid (CSF) is not indicative of bacterial meningitis. In fact, increased CSF pressure is more commonly associated with meningitis due to inflammation and increased production of CSF. Monitoring CSF pressure helps diagnose and manage meningitis but decreased pressure would not support a bacterial meningitis diagnosis.
Choice B rationale
Decreased white blood cell (WBC) count in the CSF is not consistent with bacterial meningitis. Meningitis, especially bacterial, typically causes an increased WBC count in the CSF as the body responds to the infection. This increase in WBCs, particularly neutrophils, indicates the immune system's effort to combat the bacterial invasion. A decreased count would not align with this diagnosis.
Choice C rationale
Elevated glucose levels in the cerebrospinal fluid are not typical for bacterial meningitis. Bacterial infections usually consume glucose, leading to decreased glucose levels in the CSF. Elevated glucose levels could indicate other conditions or metabolic issues but would not support a bacterial meningitis diagnosis.
Choice D rationale
Elevated total protein in the cerebrospinal fluid supports the diagnosis of bacterial meningitis. In bacterial meningitis, the inflammation and increased permeability of the blood-brain barrier lead to elevated protein levels in the CSF. This finding, along with increased WBC count and decreased glucose levels, helps confirm the diagnosis of bacterial meningitis and guides appropriate treatment. .
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