When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment finding would the nurse immediately report?

Respiration rate decrease from 40 to 32 breaths/min.

Heart rate decrease from 110 to 100 beats/min.

"Quiet chest" from previous assessment of wheezing.

Oxygen saturation of 90%.

Answer and Explanation

The Correct Answer is C

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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Correct Answer is ["50"]

Explanation

Step 1: Calculate the total puffs per day. 2 puffs/dose × 2 doses/day = 4 puffs/day.

Step 2: Calculate the number of days the inhaler will last. 200 puffs ÷ 4 puffs/day = 50 days. The inhaler will last 50 days.

A. Negative chest x-ray. B. No clinical symptoms. C. Three negative sputum cultures. D. Negative skin test.

Correct Answer is C

Explanation

Choice A rationale

A negative chest x-ray, while indicative of resolving lung pathology, does not definitively confirm the absence of viable Mycobacterium tuberculosis. Radiographic resolution can lag behind bacteriologic clearance, meaning granulomas might still be present even if the active infection has been eliminated, and thus transmissibility cannot be excluded solely based on imaging.

Choice B rationale

The absence of clinical symptoms, such as cough, fever, or weight loss, suggests clinical improvement but does not guarantee bacteriologic cure or non-infectiousness. A patient can be asymptomatic yet still shed viable mycobacteria, posing a risk of transmission to others. Bacteriological confirmation is essential.

Choice C rationale

Three negative sputum cultures, typically collected on separate days, are the gold standard for confirming that a patient with tuberculosis is no longer infectious. This indicates the absence of viable Mycobacterium tuberculosis in respiratory secretions, significantly reducing the risk of transmission to others due to the inability to aerosolize infectious particles.

Choice D rationale

A negative skin test, or tuberculin skin test (TST), indicates the absence of a delayed-type hypersensitivity reaction to M. tuberculosis antigens. It primarily reflects exposure and immune response, not active infection or infectiousness. A previously positive TST usually remains positive even after successful treatment, so a negative result in a treated patient is not a measure of non-infectiousness.

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When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment finding would the nurse immediately report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has a metered-dose inhaler that contains 200 actuations ('puffs'), and it does not have a dose counter. He is to take two puffs two times a day. If he does not take any extra doses, identify how many days will this inhaler last at the prescribed dose.

Correct Answer is ["50"]

Explanation

A patient has been compliant with drug therapy for tuberculosis (TB) and has returned as instructed for follow-up. Which result indicates that the patient is no longer infectious or communicable?

Correct Answer is C

Explanation

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