A nurse is planning care for an 8-month-old infant who has bronchiolitis. Which of the following actions should the nurse include in the plan of care?
Use a bulb syringe to suction the nares.
Initiate IV antibiotic therapy.
Administer a meningococcal vaccine upon admission.
Place the infant in a room with negative-pressure airflow.
The Correct Answer is A
Choice A reason: Using a bulb syringe to suction the nares is appropriate for an infant with bronchiolitis to help clear mucus and maintain airway patency, as bronchiolitis often causes nasal congestion.
Choice B reason: Initiating IV antibiotic therapy is not typically indicated for bronchiolitis, which is usually caused by a virus, and antibiotics are ineffective against viral infections.
Choice C reason: Administering a meningococcal vaccine upon admission is not related to the immediate care needs of an infant with bronchiolitis and is not part of standard treatment for this condition.
Choice D reason: Placing the infant in a room with negative-pressure airflow is not necessary for bronchiolitis, as this measure is reserved for airborne infections like tuberculosis, not for bronchiolitis which is spread through droplets.
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Related Questions
Correct Answer is B
Explanation
Choice A reason: Using a 20-gauge needle for injections in a 3-month-old infant is not appropriate as it is too large. A smaller gauge needle should be used to minimize pain and tissue trauma.
Choice B reason: Providing a pacifier coated with an oral sucrose solution prior to the injections is an evidence-based practice to reduce pain in infants. The sweet taste of sucrose has a soothing effect and can help to distract the infant from the discomfort of the injection.
Choice C reason: Injecting immunizations into the deltoid muscle is not recommended for a 3-month-old infant as their muscle mass is not yet fully developed. The anterolateral thigh is the preferred site for intramuscular injections in infants.
Choice D reason: Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections can help to numb the skin and reduce pain. However, it needs to be applied at least one hour before the procedure to be effective.
Correct Answer is B
Explanation
Choice A reason: Assessing vital signs every 4 hours is important, but it is not specific to the care of an infant post-cardiac catheterization. Vital signs should be monitored according to the infant's condition and hospital policy.
Choice B reason: Monitoring the color of the affected extremity is crucial after cardiac catheterization to ensure there is no compromise in blood flow, which could indicate a vascular injury or thrombosis at the catheterization site.
Choice C reason: Maintaining NPO (nothing by mouth) status for 8 hours may be necessary before the procedure, but post-catheterization care typically includes gradual reintroduction of fluids and then food as tolerated.
Choice D reason: Keeping the affected extremity flexed is not recommended post-cardiac catheterization. The limb should be kept straight to avoid bending at the catheterization site, which could lead to bleeding or clot formation.
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