A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

Request an x-ray of the preschooler's neck.

Initiate droplet precautions.

Administer fluconazole to the preschooler.

Monitor the preschooler's urine for protein

Answer and Explanation

The Correct Answer is B

The correct answer is B.

Initiate droplet precautions. The rationale is that RSV is a highly contagious viral infection that causes respiratory tract inflammation and can spread through respiratory droplets from coughing or sneezing. The nurse should wear a mask and gloves when caring for the preschooler and isolate them from other children to prevent transmission.

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Correct Answer is B

Explanation

Choice A reason

While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.

Choice B reason.

Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure

Choice C reason:

While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.

Choice D reason:

Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.

A. Neonatal Infant Pain Scale (NIPS) B. FACES pain rating scale C. Premature infant Pain Profile (PIPP) D. Visual analog scale (VAS)

Correct Answer is A

Explanation

A. Neonatal Infant Pain Scale (NIPS): The NIPS is a widely used and validated pain assessment tool specifically designed for newborns, including full-term infants like the 38-week gestation newborn in this case. It evaluates behavioral indicators such as facial expressions, crying, arm and leg movement, and physiological indicators like breathing patterns.

B. FACES pain rating scaleis designed for older children who can self-report pain by selecting a facial expression corresponding to their level of discomfort. It is not suitable for newborns who cannot self-report their pain.

C. Premature Infant Pain Profile (PIPP):The PIPP is specifically designed for preterm infants (less than 37 weeks of gestation) and assesses pain based on behavioral and physiological indicators.

D. Visual Analog Scale (VAS): The VAS requires a client to self-report their pain by indicating a point along a continuum, which is not appropriate for newborns.

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A nurse is assisting with the care of a preschooler who has manifestations of respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

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