A nurse is reviewing the laboratory test results for a 3-year-old child who has been diagnosed with RSV infection.
The nurse notes that the child’s respiratory rate is 35 breaths per minute, oxygen saturation is 96%, pH is 7.38, and PaCO2 is 40.
Which of the following actions should the nurse take based on these results? (Select all that apply).
Continue to monitor the child’s respiratory rate.
Administer supplemental oxygen.
Reassess the child’s oxygen saturation in one hour.
Notify the healthcare provider about the pH value.
Prepare for immediate intubation due to elevated PaCO2.
Correct Answer : A,C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Keeping the child calm and comfortable is generally advisable, but in the context of RSV infection, maintaining a patent airway is crucial.
While comfort measures are essential, this choice does not directly address the mother's query regarding improving the child's breathing.
Choice B rationale:
This is The correct answer because suctioning the child's nose and mouth as needed helps in removing secretions, thus maintaining a clear airway.
RSV infection often leads to increased mucus production, which can obstruct the airways, making it difficult for the child to breathe.
By suctioning secretions, the mother can help her child breathe more comfortably, which is essential in managing RSV infection.
Choice C rationale:
Over-the-counter cold medicine is generally not recommended for infants and young children due to the risk of adverse effects.
Additionally, these medications may not specifically address the underlying cause of respiratory distress in RSV infection.
Choice D rationale:
Avoiding feeding the child until their breathing improves is not appropriate advice.
Nutrition is essential, especially for infants, and withholding feeding could lead to dehydration and other complications.
It is important to maintain adequate nutrition while managing the respiratory distress caused by RSV infection.
Correct Answer is A
Explanation
Choice A rationale:
RSV infects the squamous epithelial cells of your bronchioles, alveoli, and nasal passages.
This statement is accurate.
RSV primarily targets the respiratory tract, infecting the cells lining the bronchioles, alveoli, and nasal passages.
This infection can lead to symptoms ranging from mild cold-like symptoms to severe respiratory distress, particularly in young children and individuals with weakened immune systems.
Choice B rationale:
RSV does not cause the immune system to attack the body's own cells.
It primarily targets the respiratory system, leading to respiratory symptoms.
Autoimmune responses are not associated with RSV infections.
Choice C rationale:
RSV does not lead to an overproduction of red blood cells.
This statement is incorrect and not related to the pathophysiology of RSV infections.
Choice D rationale:
RSV does not cause the body to stop producing white blood cells.
White blood cells play a crucial role in the immune response, and stopping their production would severely compromise the body's ability to fight infections.
RSV primarily affects the respiratory system and does not directly impact white blood cell production.
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