A patient who presents with symptoms of influenza that started 24 hours ago is seen by the health care provider.
Which intervention does the nurse expect for this patient?
An order for an antiviral agent such as oseltamivir.
Instructions to rest and decrease fluid intake.
Prescription for antibiotics.
Admission to an acute care facility.
The Correct Answer is A
Choice A rationale
Oseltamivir, an antiviral neuraminidase inhibitor, is most effective when administered within 48 hours of influenza symptom onset. It works by inhibiting the viral neuraminidase enzyme, preventing the release of new virions from infected cells, thereby reducing viral spread and shortening the duration and severity of illness, if given early.
Choice B rationale
Rest is indeed important for recovery from influenza, as it conserves energy and allows the immune system to combat the infection. However, decreasing fluid intake is contraindicated; adequate hydration is crucial to prevent dehydration, especially with fever, and to help thin respiratory secretions, facilitating their clearance.
Choice C rationale
Influenza is a viral infection; therefore, antibiotics, which target bacterial pathogens, are ineffective against the influenza virus itself. Administering antibiotics would be inappropriate and could contribute to antibiotic resistance without providing therapeutic benefit for the viral illness, unless a secondary bacterial infection is suspected.
Choice D rationale
Admission to an acute care facility is generally reserved for severe cases of influenza, such as those with respiratory distress, hypoxemia, or significant comorbidities. For a patient whose symptoms started only 24 hours prior and without severe complications, outpatient management with antiviral therapy is typically sufficient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Taking bronchodilators after meals can reduce their effectiveness in bronchodilation during digestion, as blood flow is shunted to the gastrointestinal tract. Optimal bronchodilation is crucial before meals to improve breathing, reduce dyspnea, and enhance food intake. This timing ensures maximum therapeutic effect of the medication when respiratory demand might increase due to the physiological process of eating.
Choice B rationale
Eating five or six small meals daily helps reduce the volume of food in the stomach at any one time, minimizing pressure on the diaphragm. This prevents diaphragmatic splinting and allows for better lung expansion, reducing the feeling of fullness and breathlessness that can occur with large meals in individuals with chronic obstructive pulmonary disease.
Choice C rationale
Resting for at least 30 minutes before eating conserves energy and reduces oxygen demand, which is vital for clients with chronic obstructive pulmonary disease. Fatigue can exacerbate dyspnea, making it difficult to consume adequate nutrition. This rest period allows the respiratory muscles to recover, making the act of eating less strenuous.
Choice D rationale
Choosing foods that are not gas-forming helps prevent abdominal distension. A distended abdomen can elevate the diaphragm, restricting lung expansion and increasing respiratory effort. Avoiding gas-producing foods reduces intra-abdominal pressure, thereby facilitating more comfortable breathing during and after meals for individuals with chronic obstructive pulmonary disease.
Correct Answer is C
Explanation
Choice A rationale
A decrease in respiration rate from 40 to 32 breaths/min in an infant with RSV, while a reduction, does not necessarily indicate immediate deterioration requiring urgent reporting unless accompanied by other signs of respiratory distress. The normal respiratory rate for an infant typically ranges from 30 to 60 breaths/min. This change might reflect an improvement or a less acute phase.
Choice B rationale
A decrease in heart rate from 110 to 100 beats/min in an infant, while a slight reduction, still falls within the normal range for an infant's heart rate (typically 90-160 beats/min). This change alone is not usually indicative of immediate critical deterioration, especially without accompanying signs of hypoxemia or circulatory compromise.
Choice C rationale
A "quiet chest" following a previous assessment of wheezing in an infant with RSV is an ominous sign. Wheezing is caused by air moving through constricted airways. A sudden cessation of wheezing, despite persistent respiratory distress, suggests severe bronchoconstriction and impending respiratory failure, as airflow has become so minimal that it no longer produces audible sounds.
Choice D rationale
An oxygen saturation of 90% is below the acceptable normal range (typically 95-100%) and indicates hypoxemia, requiring attention and intervention. However, while concerning, it is not as immediately life-threatening as a "quiet chest" which signals impending respiratory arrest due to absent air movement.
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