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 B
Explanation
Choice A reason: Preparing to administer a potassium IV bolus is not typically indicated in sickle cell crisis unless there is a documented potassium deficiency. Potassium levels must be carefully monitored to avoid hyperkalemia.
Choice B reason: Providing hydration both orally and intravenously is crucial in managing sickle cell crisis. Hydration helps to reduce blood viscosity and improve circulation, which can alleviate the pain and prevent further sickling of red blood cells.
Choice C reason: Requesting a prescription for meperidine is not recommended for pain management in sickle cell crisis due to the risk of seizures and other side effects. Other pain medications, such as morphine, are preferred.
Choice D reason: Administering multiple units of platelets is not a standard treatment for sickle cell crisis. Platelet transfusion is typically reserved for patients with thrombocytopenia or active bleeding, not for sickle cell crisis.
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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