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.
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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Related Questions
Correct Answer is C
Explanation
A. "I will cook foods that are low in fat and carbohydrates.": Children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B. "My child can chew their enzyme medication with meals.": Enzyme medications should not be chewed as they can irritate the oral mucosa; they should be swallowed whole or sprinkled on soft food.
C. "I will give my child stool softeners for constipation." Constipation is a common issue in cystic fibrosis due to thickened intestinal secretions. Stool softeners help prevent this complication.
D. "My child will be excused from physical education class.": Physical activity is encouraged for children with cystic fibrosis to improve lung function.
Correct Answer is D
Explanation
A. "I will set the temperature of the hot water heater to 140 degrees." The hot water heater should be set to 120°F (49°C) or lower to prevent scald injuries. A setting of 140°F significantly increases the risk of burns.
B. "I will turn pot handles towards the front of the stove when cooking." Pot handles should be turned toward the back of the stove to prevent a child from grabbing or knocking them over.
C. "I don't need to apply sunscreen to my child if he is outside after 3 p.m." Sunscreen is essential any time a child is outdoors during daylight, regardless of the time, to protect against harmful UV rays.
D. "I will plug protective guards into my electrical outlets." Installing protective guards helps prevent electrical burns by stopping toddlers from inserting objects into outlets.
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