A nurse is planning care for an 8-month-old infant who has bronchiolitis. Which of the following actions should the nurse include in the plan of care?
Use a bulb syringe to suction the nares.
Initiate IV antibiotic therapy.
Administer a meningococcal vaccine upon admission.
Place the infant in a room with negative-pressure airflow.
The Correct Answer is A
Choice A reason: Using a bulb syringe to suction the nares is appropriate for an infant with bronchiolitis to help clear mucus and maintain airway patency, as bronchiolitis often causes nasal congestion.
Choice B reason: Initiating IV antibiotic therapy is not typically indicated for bronchiolitis, which is usually caused by a virus, and antibiotics are ineffective against viral infections.
Choice C reason: Administering a meningococcal vaccine upon admission is not related to the immediate care needs of an infant with bronchiolitis and is not part of standard treatment for this condition.
Choice D reason: Placing the infant in a room with negative-pressure airflow is not necessary for bronchiolitis, as this measure is reserved for airborne infections like tuberculosis, not for bronchiolitis which is spread through droplets.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: Clearing the area of hard objects is crucial to prevent injury during a seizure. It helps to ensure that the child does not hit or get hurt by any objects in the vicinity while experiencing convulsions.
Choice B reason: Minimizing movement of the limbs is not recommended as it can cause injury to the child. Instead, the child should be allowed to move freely without restraint to avoid causing harm to their joints or muscles.
Choice C reason: Inserting a tongue blade between the teeth is an outdated and dangerous practice. It can cause injury to the child's mouth or teeth and may lead to choking if the tongue blade breaks.
Choice D reason: Placing the child in a prone position is not advised as it can obstruct the airway. The child should be placed on their side in the recovery position to keep the airway clear and allow fluids to drain from the mouth.
Correct Answer is D
Explanation
Choice Areason: An upper respiratory infection 2 days ago, if the child is currently well, is not a contraindication for the MMR vaccine. Vaccines can be given to children with a minor illness.
Choice Breason: A temperature of 37.2° C (99°F) is a mild elevation and is not a contraindication for receiving the MMR vaccine. Vaccination can proceed if the child is only mildly ill.
Choice C reason: A family history of seizures is not a contraindication for the MMR vaccine. While there is a small risk of febrile seizures, the benefits of vaccination outweigh the risks.
Choice D reason: An allergy to neomycin is a contraindication for the MMR vaccine because neomycin is used in the vaccine production process. Children with a known severe allergic reaction to neomycin should not receive the vaccine.
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