A nurse is caring for a toddler who is hospitalized with respiratory syncytial virus (RSV). Which of the following nursing interventions is the priority?
Administer prescribed antipyretics for a temperature of 38.5°C (101.3°F)
Encourage the child to drink small, frequent amounts of fluids
Monitor oxygen saturation and apply humidified oxygen if needed
Place the child on contact and droplet precautions
The Correct Answer is C
A. Fever is a common symptom of RSV, and antipyretics can improve comfort. However, fever itself is not life-threatening and does not directly address the risk of airway compromise or hypoxia. Therefore, antipyretics are secondary to interventions that support breathing and oxygenation.
B. Hydration is important because RSV can cause poor oral intake, dehydration, and increased mucus viscosity, which may worsen airway obstruction. While promoting fluids is necessary, it is not as urgent as ensuring adequate oxygenation.
C. Continuous monitoring of oxygen saturation allows for early detection of hypoxemia. Hypoxia can develop rapidly in infants and toddlers with RSV due to their smaller airway size and limited respiratory reserve. Humidified oxygen helps maintain airway moisture, reduces airway irritation, and supports gas exchange. Ensuring adequate oxygenation prevents complications such as respiratory failure, apnea, or cardiac compromise, making it the highest priority intervention.
D. RSV is highly contagious and spreads via respiratory droplets and direct contact. Precautions are essential to protect staff and other patients, but infection control measures do not address the immediate threat to the patient’s respiratory status. Priority interventions must first ensure the child’s airway and oxygenation are stable.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Infants actually have smaller airway diameters and less lung volume than adults. A larger airway and fully developed lungs would decrease susceptibility to respiratory compromise, not increase it.
B. Infants’ airways are narrow, so even minor swelling or mucus buildup can significantly obstruct airflow. Additionally, respiratory muscles, including the diaphragm and intercostals, are immature and fatigue easily, making it harder for infants to maintain adequate ventilation during illness or stress. These factors increase the risk of rapid respiratory compromise.
C. Infants have fewer alveoli and less surface area for gas exchange, and their respiratory muscles are weaker than adults, not stronger. This contributes to increased risk, not protection.
D. The diaphragm is less developed in infants, and their chest wall is more compliant, which can lead to paradoxical movements and less effective ventilation. Increased diaphragm development and lung compliance would enhance respiratory function, not increase susceptibility.
Correct Answer is C
Explanation
A. Nutrition is important in CF because malabsorption is common, but addressing malnutrition is not the immediate priority when the child is experiencing respiratory compromise. Nutritional interventions are secondary to airway management.
B. Inhaled corticosteroids can help reduce chronic airway inflammation, but they do not remove existing mucus or immediately improve airflow. They are part of long-term management rather than urgent treatment during an exacerbation.
C. CPT is the cornerstone of CF management, particularly during exacerbations. Techniques such as percussion, postural drainage, and vibration help mobilize thick mucus, improve airway clearance, enhance oxygenation, and reduce the risk of infection and further lung damage. Immediate airway clearance is critical for symptom relief and prevention of respiratory complications.
D. Adequate hydration can support mucus thinning but is not sufficient alone to manage an acute pulmonary exacerbation. It is adjunctive, supporting other interventions like CPT and medications.
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