A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Initiate contact precautions.

Perform chest percussion and postural drainage.

Encourage clear liquids by mouth.

Administer IV antibiotics.

Answer and Explanation

The Correct Answer is A

A. Initiate contact precautions: RSV is a highly contagious respiratory virus spread via droplets and direct contact. To prevent transmission to others, contact precautions should be initiated.
B. Perform chest percussion and postural drainage: While these techniques can be used in some respiratory conditions, they are not the first-line intervention for RSV.
C. Encourage clear liquids by mouth: While oral rehydration may be appropriate in some cases of mild dehydration, this infant is likely experiencing respiratory distress, and oral intake may be difficult. Intravenous fluids may be required, especially if the infant is having difficulty feeding.
D. Administer IV antibiotics: RSV is caused by a virus, not a bacterial infection, so antibiotics are not effective in treating the infection.

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Correct Answer is C

Explanation

A. "My child will be awake for this procedure.": Incorrect because the child will be under sedation or anesthesia for safety and to prevent distress.
B. "I can take my child home as soon as the procedure is over.": Incorrect because the child must be monitored post-procedure for complications like airway swelling or sedation effects.
C. "The provider will remove the object during this procedure." A bronchoscopy allows visualization and removal of foreign objects from the airway, which is the purpose of the procedure.
D. "After this procedure, I have to wait 48 hours before I can give my child solid foods.": Incorrect because eating is typically resumed after the child recovers from sedation and demonstrates a safe swallow reflex.

A. Face, legs, activity, cry, consolability (FLACC) scale B. Oucher scale C. FACES scale D. Visual analog scale (VAS)

Correct Answer is A

Explanation

A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.

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A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

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