The nurse is caring for a 10-month-old infant diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the child's care? (Select all that apply.).
Institute cluster care to encourage adequate rest.
Administer cough syrup.
Administer antibiotics.
Encourage infant to drink 8 ounces of formula every 4 hours.
Place on noninvasive oxygen monitoring.
Correct Answer : A,E
The correct answers are choices A and E: Institute cluster care to encourage adequate rest and Place on noninvasive oxygen monitoring.
Choice A rationale:
Institute cluster care to encourage adequate rest. This is a correct choice. Cluster care involves grouping nursing interventions together to minimize disruptions to the child's rest. Adequate rest is crucial for the healing process in infants with respiratory syncytial virus (RSV) bronchiolitis.
Choice B rationale:
Administer cough syrup. This choice is incorrect for RSV bronchiolitis. Cough syrup is not recommended for infants with bronchiolitis. RSV primarily affects the lower respiratory tract and can cause airway inflammation, making cough syrup potentially ineffective and unnecessary.
Choice C rationale:
Administer antibiotics. This choice is incorrect for RSV bronchiolitis. RSV is a viral infection, and antibiotics are ineffective against viruses. Antibiotics should only be used when there is a bacterial infection or a clear indication.
Choice D rationale:
Encourage infant to drink 8 ounces of formula every 4 hours. This choice is not the best approach for managing RSV bronchiolitis. Infants with RSV may experience decreased appetite due to respiratory distress. Smaller, more frequent feedings are often recommended to prevent overfeeding and aspiration.
Choice E rationale:
Place on noninvasive oxygen monitoring. This is a correct choice. RSV bronchiolitis can cause respiratory distress and compromise oxygenation. Noninvasive oxygen monitoring helps assess the child's oxygen levels and aids in determining the need for supplemental oxygen therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Increased appetite is a common side effect of corticosteroid therapy. Corticosteroids are known to affect various metabolic processes, and one of the effects is an increase in appetite. This can lead to weight gain, especially when the increased calorie intake is not balanced by physical activity.
Choice B rationale:
Fever is not a typical side effect of corticosteroid therapy. Corticosteroids are often used to reduce inflammation and suppress the immune response, which can help in managing conditions like autoimmune diseases, allergies, and inflammatory disorders. Fever is not a direct result of corticosteroid administration.
Choice C rationale:
Weight loss is not a common side effect of corticosteroid therapy. In fact, corticosteroids are more likely to cause weight gain due to their influence on appetite, metabolism, and fluid retention.
Choice D rationale:
Hypertension (high blood pressure) can indeed be a side effect of corticosteroid therapy. Corticosteroids can lead to sodium and water retention, which can contribute to increased blood pressure, particularly in individuals who are already at risk for hypertension. However, among the options provided, increased appetite is a more directly associated side effect of corticosteroid therapy.
Correct Answer is C
Explanation
The correct answer is choice C. Therapeutic management includes administration of gamma globulin and aspirin.
Choice A rationale:
The child's fever in Kawasaki disease is not usually responsive to antibiotics within 48 hours. Kawasaki disease is an inflammatory condition of blood vessels, and it doesn't typically respond to antibiotics. The fever associated with Kawasaki disease often persists even with appropriate treatment, and the management focuses on reducing inflammation and preventing complications.
Choice B rationale:
Aspirin is not contraindicated in Kawasaki disease. In fact, aspirin is a key component of the therapeutic management of Kawasaki disease. It is used to reduce inflammation and prevent the development of coronary artery aneurysms, a severe complication of the disease. However, the dosing of aspirin in Kawasaki disease is different from its use for pain relief, and it should be administered under medical supervision.
Choice C rationale:
Therapeutic management of Kawasaki disease does include administration of gamma globulin and aspirin. Gamma globulin is given to reduce the risk of coronary artery involvement and aneurysm formation. Aspirin, at a specific dose regimen, is used to decrease inflammation and platelet aggregation, thus preventing clot formation in the coronary arteries.
Choice D rationale:
The principal area of involvement in Kawasaki disease is not the joints. Kawasaki disease primarily affects the blood vessels, particularly the coronary arteries. The inflammation of these arteries can lead to the development of coronary artery aneurysms, which is a critical concern in Kawasaki disease. Joint involvement is not a prominent feature of this condition.
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