A nurse is collecting data from a client who has hyponatremia.
Which of the following findings should the nurse expect?

Choice A rationale:

"Request an x-ray of the preschooler's neck." - This action is not indicated for a preschooler with manifestations of respiratory syncytial virus (RSV) RSV primarily affects the respiratory system, and an x-ray of the neck would not be relevant for this condition.

Choice B rationale:

"Initiate droplet precautions." - This is the correct answer. RSV is highly contagious and primarily spreads through respiratory droplets. Initiating droplet precautions, such as wearing a mask and practicing proper hand hygiene, is essential to prevent the transmission of the virus to others in the healthcare setting.

Choice C rationale:

"Administer fluconazole to the preschooler." - Fluconazole is an antifungal medication and would not be appropriate for treating RSV, which is a viral respiratory infection. Antifungal medications are used to treat fungal infections, not viral ones.

Choice D rationale:

"Monitor the preschooler's urine for protein." - Monitoring urine for protein is not relevant to the care of a preschooler with RSV. This action is more suitable for conditions that may affect the kidneys or urinary system but not RSV, which primarily affects the respiratory system.

Choice A rationale:

Pedal pulses are a measure of peripheral circulation. A 2+ rating is considered normal, indicating a brisk, expected response. There’s no change in the client’s pedal pulses from Day 1 to Day 5, so this doesn’t require immediate follow-up.

Choice B rationale:

Oxygen saturation is not mentioned in the Nurses’ Notes, so we cannot provide a rationale for this choice.

Choice C rationale:

Breath sounds are an important indicator of respiratory health. The client’s breath sounds are clear and present throughout on both Day 1 and Day 5, which is normal and doesn’t require immediate follow-up.

Choice D rationale:

Respiratory rate is not mentioned in the Nurses’ Notes, but any significant change in respiratory rate could indicate a problem such as infection or pain, and would require immediate follow-up.

Choice E rationale:

The abdominal dressing shows a large amount of serosanguinous drainage on Day 5, compared to a small amount on Day 1. This could indicate a complication such as infection or dehiscence (separation of the wound), especially since the client reported feeling something “popped” at the incision site after coughing. This requires immediate follow-up.

Choice F rationale:

Heart rate is not mentioned in the Nurses’ Notes, but any significant change in heart rate could indicate a systemic response to factors such as pain or infection, and would require immediate follow-up. In summary, while pedal pulses and breath sounds remain normal, the change in the abdominal dressing and potential changes in respiratory rate and heart rate (though not documented here) should be addressed immediately to ensure the client’s health and recovery.