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 B
Explanation
Choice A rationale:
Hypoparathyroidism is not associated with exophthalmos. Hypoparathyroidism is a condition where the parathyroid glands produce insufficient parathyroid hormone, leading to low calcium levels in the blood. This condition doesn't directly affect the thyroid gland or cause exophthalmos.
Choice B rationale:
Exophthalmos, also known as protruding or bulging eyes, is a classic symptom of hyperthyroidism. Hyperthyroidism is a condition where the thyroid gland produces excessive amounts of thyroid hormones. These elevated hormone levels can lead to a variety of symptoms, including increased metabolism, weight loss, nervousness, and protruding eyes due to inflammation of the eye muscles and tissues behind the eye.
Choice C rationale:
Hyperparathyroidism involves the overactivity of the parathyroid glands, leading to excessive production of parathyroid hormone (PTH) and elevated calcium levels in the blood. While elevated calcium levels can have various effects on the body, exophthalmos is not a typical manifestation of hyperparathyroidism. The condition is more commonly associated with bone and kidney issues.
Choice D rationale:
Hypothyroidism, the underproduction of thyroid hormones by the thyroid gland, is not linked to exophthalmos. Instead, hypothyroidism is known for causing symptoms such as fatigue, weight gain, cold intolerance, and slow heart rate. Exophthalmos is a characteristic sign of hyperthyroidism, not hypothyroidism.
Correct Answer is A
Explanation
The correct answer is Choice A.Choice A rationale:Vomiting is a common sign of digoxin toxicity. It occurs due to the drug's effects on the gastrointestinal system, which can lead to nausea and vomiting as the body attempts to expel the toxin. This symptom is particularly significant as it can indicate elevated digoxin levels that may require medical intervention.Choice B rationale:Tachycardia, or an increased heart rate, can occur with digoxin toxicity; however, it is more commonly associated with inadequate therapeutic levels rather than toxicity itself. Digoxin usually causes bradycardia (a slower heart rate) when at therapeutic levels, making tachycardia less indicative of toxicity.Choice C rationale:Bradypnea, or slow breathing, is not a typical sign of digoxin toxicity. While respiratory issues can arise from various conditions, they are not specifically linked to digoxin levels. Monitoring respiratory rate is essential in clinical settings but does not directly correlate with digoxin toxicity.Choice D rationale:Seizures are not a common sign of digoxin toxicity. While severe cases might lead to neurological symptoms due to electrolyte imbalances or other complications, seizures are not typically associated with digoxin overdose. Instead, they may suggest other underlying issues requiring evaluation.
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