A nurse is caring for a toddler who has been admitted with RSV infection.
The toddler’s symptoms include wheezing, retractions, nasal flaring, tachypnea, and cyanosis.
The nurse understands that these symptoms indicate severe respiratory distress, which is common in children younger than age 3 with RSV infection.
Which of the following interventions should be included in the toddler’s care plan?
Administer bronchodilators as prescribed.
Encourage fluid intake.
Monitor oxygen saturation levels.
All of these.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Offering frequent small feedings of breast milk or formula to maintain nutrition is an appropriate response.
Infants with RSV may experience decreased appetite and difficulty feeding due to respiratory distress.
Providing small, frequent feedings ensures that the infant receives adequate nutrition and hydration despite reduced intake during each feeding session.
Choice A rationale:
Giving the baby aspirin if they develop a fever is not recommended.
Aspirin use in children with viral infections like RSV has been associated with Reye's syndrome, a severe and potentially fatal condition.
Acetaminophen or ibuprofen, if appropriate for the child's age, can be used to manage fever and discomfort.
Choice C rationale:
Keeping the baby in a flat position to promote comfort is not advisable.
Elevating the head of the crib or bassinet slightly can help improve breathing and reduce nasal congestion in infants with respiratory infections, promoting better comfort and easier breathing.
Choice D rationale:
Stopping all feedings if the baby seems to be having trouble breathing is not The correct approach.
Adequate nutrition is crucial for the infant's overall health and recovery.
Instead, the caregiver should seek medical advice if the baby experiences significant difficulty breathing or feeding.
Adjustments in feeding techniques or temporary alternative feeding methods may be recommended under medical supervision.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
This statement is incorrect.
A history of recurrent pneumonia is not a specific indicator of RSV infection.
RSV primarily affects the respiratory system, causing symptoms such as cough, wheezing, and difficulty breathing.
Choice B rationale:
This is a correct answer.
RSV symptoms typically appear 2 to 5 days after exposure.
Including this option helps identify the duration of symptoms, which is relevant to diagnosing RSV.
Choice C rationale:
This is a correct answer.
RSV commonly presents with symptoms like high fever and severe cough.
Recognizing these symptoms can help healthcare providers consider RSV as a possible diagnosis.
Choice D rationale:
This is a correct answer.
RSV can lead to bronchiolitis, which is inflammation of the small airways in the lungs.
Diagnosing a child with bronchiolitis can raise suspicion of RSV infection.
Choice E rationale:
This statement is incorrect.
A history of bacterial infections is not specific to RSV and does not provide relevant information for identifying RSV infection in this context.
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