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).
Isolate the child from other children or adults with respiratory infections.
Use contact precautions such as gown and gloves when caring for the child.
Encourage frequent hand hygiene.
Allow siblings to share toys and utensils with the infected child.
Avoid exposure to tobacco smoke.
Correct Answer : A,B,C,E
Choice A rationale:
Isolating the child from other children or adults with respiratory infections is crucial in preventing the spread of Respiratory Syncytial Virus (RSV).
RSV is highly contagious and spreads through respiratory droplets.
By isolating the infected child, the nurse helps prevent the transmission of the virus to others.
Choice B rationale:
Using contact precautions such as gown and gloves when caring for the child is essential to prevent the spread of RSV.
Direct contact with respiratory secretions can easily lead to transmission.
Wearing protective gear like gowns and gloves creates a barrier, reducing the risk of contamination and spread.
Choice C rationale:
Encouraging frequent hand hygiene is a fundamental preventive measure.
RSV can survive on surfaces for several hours, so regular handwashing with soap and water for at least 20 seconds can help eliminate the virus from hands, reducing the risk of infection.
Choice E rationale:
Avoiding exposure to tobacco smoke is important because smoke irritates the respiratory tract, making individuals more susceptible to respiratory infections like RSV.
Secondhand smoke can also worsen symptoms in infected individuals and increase the severity of the illness.
Choice D rationale:
Allowing siblings to share toys and utensils with the infected child is not recommended.
RSV spreads through respiratory droplets and direct contact with contaminated surfaces.
Sharing toys and utensils can facilitate the transmission of the virus to other children, increasing the risk of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C"]
Explanation
Choice A rationale: The child’s respiratory rate of 35 breaths per minute is slightly elevated but not uncommon for a 3-year-old with a respiratory infection like RSV. Given the child's oxygen saturation is 96%, which is within normal range, it is appropriate to continue monitoring the respiratory rate. Monitoring ensures any changes in the child’s condition can be promptly addressed without unnecessary interventions.
Choice B rationale: Administering supplemental oxygen is not necessary in this case because the child’s oxygen saturation is 96%, which is within the normal range (95-100%). Providing supplemental oxygen without clinical indication can cause potential harm and is not warranted when oxygen levels are adequate.
Choice C rationale: Reassessing the child’s oxygen saturation in one hour is a prudent action. This allows the nurse to ensure that the child’s oxygen levels remain stable and to detect any potential decline in respiratory function. It provides an ongoing assessment to ensure the child's condition does not worsen.
Choice D rationale: The pH value of 7.38 is within the normal range (7.35-7.45), indicating that the child is not experiencing acid-base imbalance. There is no immediate need to notify the healthcare provider about the pH value alone, as it does not suggest any critical condition requiring urgent intervention.
Choice E rationale: Preparing for immediate intubation due to elevated PaCO2 is not warranted. The child’s PaCO2 is 40, which is within the normal range for carbon dioxide levels (35-45 mmHg). Intubation is a severe intervention reserved for cases of respiratory failure, which is not indicated by the presented lab results.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should reassure the client by stating, “We will monitor your child closely for any signs of respiratory distress.”.
This is the appropriate response because close monitoring is crucial in children with RSV infection, especially those younger than age 3.
Respiratory distress can rapidly progress in this age group, and early detection is essential for timely intervention.
Monitoring the child's respiratory rate, oxygen saturation, and other respiratory symptoms allows healthcare providers to assess the severity of the condition and provide appropriate interventions promptly.
Choice B rationale:
While ensuring rest and fluids is generally good advice for managing various illnesses, it does not specifically address the client’s concerns about the potential complications of RSV infection, such as bronchiolitis or pneumonia leading to respiratory distress.
Choice C rationale:
Administering medication to reduce fever is not the most pertinent information in this scenario.
The primary concern for the client is the progression of RSV infection to severe respiratory distress, not fever reduction.
Choice D rationale:
Providing a special diet to improve appetite does not address the client’s concerns about the respiratory complications associated with RSV infection.
Respiratory distress is the main worry in this situation, and dietary changes are not the appropriate focus.
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