A nurse is providing teaching to the guardians of a child who has respiratory syncytial virus (RSV). Which of the following information should the nurse include?

A. Place the client in a supine position: The supine position can worsen dyspnea by limiting diaphragmatic movement and decreasing lung expansion. Clients with respiratory distress should be positioned upright or semi-Fowler’s to facilitate breathing.

B. Instruct the client to perform diaphragmatic breathing: Diaphragmatic breathing helps improve oxygenation and ventilation by promoting deeper, more efficient breaths. It also reduces accessory muscle use and can decrease anxiety associated with shortness of breath.

C. Increase oxygen flow rate to 4 L/min: Oxygen should be titrated to maintain target saturation (usually 92–94% for COPD risk patients). The client’s current oxygen saturation is 92% on 2 L/min, so increasing the flow is unnecessary at this time.

D. Assess the client's breath sounds: Ongoing assessment of breath sounds is essential to monitor for changes such as wheezing, crackles, or diminished air entry, which guide interventions and evaluate response to therapy.

E. Restrict the client's fluid intake: Fluid restriction is not indicated in this client’s current presentation. Adequate hydration helps thin secretions, making coughing and airway clearance more effective.

F. Perform chest percussion and vibration: Chest physiotherapy techniques like percussion and vibration can help loosen and mobilize secretions, improving airway clearance in clients with productive cough and retained secretions.

A. Unstageable: An unstageable pressure injury occurs when the full thickness of tissue loss is obscured by slough or eschar. Since subcutaneous fat and tunneling are visible in this case, the injury can be staged and is not unstageable.

B. Stage 2: Stage 2 pressure injuries involve partial-thickness skin loss with exposed dermis. They do not extend into subcutaneous tissue and do not present with tunneling or visible fat, so this stage does not fit the description.

C. Stage 3:A Stage 3 pressure injury involves full-thickness skin loss. At this stage, subcutaneous fat (adipose tissue) is visible within the ulcer. Features like tunneling (a narrow opening or passageway extending from the wound) and undermining (tissue destruction underneath the intact skin at the wound edge) are common. However, the nurse should not be able to see bone, tendon, or muscle; if these deeper structures were visible, the injury would be classified as Stage 4.

D. Stage 4:A Stage 4 pressure injury involves full-thickness skin and tissue loss. The distinguishing factor for Stage 4 is the direct visualization or palpation of fascia, muscle, tendon, ligament, cartilage, or bone within the ulcer. While tunneling can occur in Stage 4, the presence of only subcutaneous fat keeps this specific injury at Stage 3.