The nurse identifies the following during the assessment of a 3-month-old with RSV: Heart rate of 140: Respiratory rate of 32: Oxygen saturation is 89% on room air: inspiratory and expiratory wheezing in upper lobes: temperature of 101 F: large amounts of thin secretions. What is the priority nursing action at this time?
Provide a quiet environment for the infant
Place an 02 via nasal cannula for the low saturation
Suction the nares and oropharynx to remove secretions
Administer acetaminophen to reduce fever
The Correct Answer is C
Rationale:
A. A quiet environment is helpful in reducing stress, but it does not address the immediate respiratory compromise.
B. Oxygen therapy may be necessary, but airway clearance must be addressed first to ensure oxygen can be effectively delivered.
C. Suctioning the nares and oropharynx is the priority because the infant has large amounts of secretions, which are likely obstructing the airway and contributing to low oxygen saturation. Clearing the airway will improve oxygenation and respiratory effort.
D. Reducing fever is important for comfort, but does not address the urgent respiratory distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E","F"]
Explanation
Rationale:
A. Cyanotic skin indicates hypoxia and is a medical emergency requiring immediate intervention.
B. Nasal flaring is a sign of increased respiratory effort and distress in infants.
C. Productive cough is uncommon in young infants and less likely to be observed due to their limited ability to expectorate secretions.
D. Crying during feeding may indicate difficulty breathing while feeding, a sign of respiratory compromise.
E. Intercostal retractions reflect increased work of breathing and respiratory distress.
F. Head bobbing is a late sign of respiratory distress in infants and suggests fatigue and possible impending respiratory failure.
Correct Answer is C
Explanation
Rationale:
A. Hypoglycemia is not typically a concern with mononucleosis and does not require scheduled snacks.
B. Mononucleosis is caused by the Epstein-Barr virus, and antibiotics are not indicated unless there is a secondary bacterial infection.
C. Avoiding contact sports is essential because mononucleosis can cause splenomegaly (enlarged spleen), which increases the risk of splenic rupture—a serious and potentially life-threatening complication.
D. Aspirin is not recommended for adolescents due to the risk of Reye's syndrome.
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