A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Initiate contact precautions.

Perform chest percussion and postural drainage.

Encourage clear liquids by mouth.

Administer IV antibiotics.

Answer and Explanation

The Correct Answer is A

A. Initiate contact precautions: RSV is a highly contagious respiratory virus spread via droplets and direct contact. To prevent transmission to others, contact precautions should be initiated.
B. Perform chest percussion and postural drainage: While these techniques can be used in some respiratory conditions, they are not the first-line intervention for RSV.
C. Encourage clear liquids by mouth: While oral rehydration may be appropriate in some cases of mild dehydration, this infant is likely experiencing respiratory distress, and oral intake may be difficult. Intravenous fluids may be required, especially if the infant is having difficulty feeding.
D. Administer IV antibiotics: RSV is caused by a virus, not a bacterial infection, so antibiotics are not effective in treating the infection.

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Correct Answer is ["A","B","C","F","G","H"]

Explanation

A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.

A. The child's BMI B. The child's pancreatic enzyme dose C. The child's diet D. The child's stool analysis

Correct Answer is A

Explanation

A. The child's BMI: Children with cystic fibrosis often have difficulty absorbing nutrients due to pancreatic insufficiency. Monitoring the child's BMI provides a good overall indicator of nutritional status, as it accounts for both weight and height.
B. The child's pancreatic enzyme dose: While important, the enzyme dose is adjusted to help the child digest food, but it does not directly assess nutritional status.
C. The child's diet: The diet is important, but it doesn't provide a direct, quantifiable measure of nutritional status. It's more of a management tool.
D. The child's stool analysis: Stool analysis can help assess malabsorption, but it does not directly reflect overall nutritional status in terms of growth or weight gain.

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A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a school-age child. Exhibits The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

Correct Answer is ["A","B","C","F","G","H"]

Explanation

A nurse in an outpatient clinic is caring for a school-age child who has cystic fibrosis. Which of the following findings should the nurse monitor as the best indication of the child's nutritional status?

Correct Answer is A

Explanation

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