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. Elevate the child's residual limb for 48 hr. Elevation for prolonged periods can cause flexion contractures. Elevation is typically limited to the first 24 hours, if at all.
B. Apply a loose-fitting bandage onto the child's residual limb. A compression bandage, not loose-fitting, is used to shape the residual limb and reduce swelling.
C. Perform active and isotonic range-of-motion exercises. These exercises prevent contractures and maintain muscle strength.
D. Clean the incision using half-strength hydrogen peroxide every 8 hr. Hydrogen peroxide can damage healthy tissue and delay healing. Saline or antiseptic solutions are preferred.

A. Administer the medication on an empty stomach. B. Entourage the child to brush their teeth after each meal. C. Crush the child's medication to mix with applesauce. D. Observe the child for diarrhea.

Correct Answer is B

Explanation

A. "Administer the medication on an empty stomach." Phenytoin can be taken with or without food. Administering with food can reduce stomach upset.
B. "Encourage the child to brush their teeth after each meal." Phenytoin increases the risk of gingival hyperplasia, so regular brushing helps maintain oral hygiene and prevents complications.
C. "Crush the child's medication to mix with applesauce." Extended-release capsules should not be crushed as this alters their intended release mechanism.
D. "Observe the child for diarrhea." Diarrhea is not a common side effect of phenytoin. Monitoring should focus on side effects like gingival overgrowth, nystagmus, or skin rashes.

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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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