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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Emotional separation from parents is a part of the normal individuation process that occurs during adolescence, but it is not as immediate or noticeable as mood swings during early adolescence.
Choice B reason: Mood swings are common during early adolescence due to hormonal changes and the development of the child's identity. This can result in rapid and intense emotional responses to situations.
Choice C reason: Increased self-esteem is a possible outcome of successful navigation through adolescence, but it is not guaranteed and is not a characteristic that can be expected to manifest uniformly during early adolescence.
Choice D reason: A decelerating growth rate is more characteristic of late adolescence after the major growth spurts have occurred. Early adolescence is typically a time of continued growth and development.
Correct Answer is C
Explanation
Choice A reason: Assessing the child's pulse and respirations can indicate pain through physiological changes, but these signs can be influenced by other factors and may not provide an accurate measure of pain intensity.
Choice B reason: Observing the child's facial expressions can give some indication of pain, but it is subjective and may not accurately reflect the child's pain experience, especially if the child is trying to hide their discomfort.
Choice C reason: Asking the child to use a FACES rating scale allows the child to actively participate in communicating their pain level. This method is age-appropriate and provides a visual way for children to express the intensity of their pain, making it a reliable assessment technique.
Choice D reason: Monitoring the child's involuntary movements can provide clues about pain, but like facial expressions, they are subjective and may not accurately quantify the child's pain level.
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