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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

This is The correct answer because it addresses the client's concern about dehydration.

Infants and young children with RSV infection are at risk of dehydration due to increased respiratory effort, fever, and decreased oral intake.

Encouraging oral fluids or providing intravenous fluids as prescribed helps prevent dehydration, ensuring the child remains hydrated during the illness.

Choice B rationale:

While adequate fluid intake is essential, stating a specific quantity like 8 glasses of water a day is not appropriate for infants and young children.

The fluid requirements vary based on the child's age, weight, and overall health condition.

Providing a specific quantity without proper assessment can be misleading and may not meet the child's individual needs.

Choice C rationale:

Limiting the child's fluid intake to prevent overhydration is not the primary concern in this context.

Dehydration due to increased respiratory effort and decreased oral intake is a more significant concern.

Adequate hydration is crucial in preventing complications associated with dehydration.

Choice D rationale:

Restricting the child to clear liquids only is not appropriate, especially in the context of RSV infection.

While clear liquids are essential, they may not provide adequate nutrition.

Maintaining appropriate oral intake, which includes a variety of fluids and, if possible, nutritionally balanced foods, is important for the child's overall well-being during the illness.

A. “Remember, RSV is most common in the summer and fall, so it’s important to take extra precautions during these months.”. B. “RSV often occurs in yearly outbreaks in communities, classrooms, and childcare centers, especially in winter and early spring.”. C. “RSV is not seasonal, so you don’t need to worry about when it occurs.”. D. “RSV only affects adults, so your children are safe.”..

Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect.

RSV is most common in winter and early spring, not summer and fall.

Stating this misinformation would not effectively educate the parents about RSV prevention during the high-risk months.

Choice B rationale:

This is The correct answer.

RSV does occur in yearly outbreaks, especially in winter and early spring.

By emphasizing this, the nurse educates parents about the specific periods when they should take extra precautions to prevent RSV transmission.

Choice C rationale:

This statement is incorrect.

RSV is indeed seasonal, with higher incidence during the winter and early spring months.

Denying its seasonality would provide inaccurate information to the parents.

Choice D rationale:

This statement is incorrect.

RSV primarily affects infants and young children, not adults.

Providing this misinformation would not help parents understand the risks associated with RSV for their children.

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Naxlex Comprehensive Predictor Exams

A client’s child has been diagnosed with RSV.The client is concerned about the risk of dehydration for their child.The nurse reassures the client by saying which of the following?

Correct Answer is A

Explanation

A nurse is educating a group of parents about RSV.The nurse wants to emphasize the importance of prevention, especially in the winter and early spring months.Which of the following statements would be most effective for the nurse to use?

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a child with a suspected RSV infection.Which of the following findings should alert the nurse that the child may have RSV? (Select all that apply).

A nurse is caring for a client who has been diagnosed with RSV.The client is concerned about the risk of transmission to their young grandchildren.Which of the following statements should the nurse make?

A nurse is educating a client on how to prevent the spread of RSV at home.Which of the following instructions should the nurse include? (Select all that apply).

A client with RSV asks a nurse about the pathophysiology of their infection.Which of the following explanations should the nurse provide?

A client’s infant has been diagnosed with RSV and the nurse is providing education on management at home.Which of the following statements by the client indicates an understanding of the teaching?