A nurse is reviewing the laboratory test results for a 3-year-old child who has been diagnosed with RSV infection.
The nurse notes that the child’s respiratory rate is 35 breaths per minute, oxygen saturation is 96%, pH is 7.38, and PaCO2 is 40.
Which of the following actions should the nurse take based on these results? (Select all that apply).
Continue to monitor the child’s respiratory rate.
Administer supplemental oxygen.
Reassess the child’s oxygen saturation in one hour.
Notify the healthcare provider about the pH value.
Prepare for immediate intubation due to elevated PaCO2.
Correct Answer : A,C
Choice A rationale: The child’s respiratory rate of 35 breaths per minute is slightly elevated but not uncommon for a 3-year-old with a respiratory infection like RSV. Given the child's oxygen saturation is 96%, which is within normal range, it is appropriate to continue monitoring the respiratory rate. Monitoring ensures any changes in the child’s condition can be promptly addressed without unnecessary interventions.
Choice B rationale: Administering supplemental oxygen is not necessary in this case because the child’s oxygen saturation is 96%, which is within the normal range (95-100%). Providing supplemental oxygen without clinical indication can cause potential harm and is not warranted when oxygen levels are adequate.
Choice C rationale: Reassessing the child’s oxygen saturation in one hour is a prudent action. This allows the nurse to ensure that the child’s oxygen levels remain stable and to detect any potential decline in respiratory function. It provides an ongoing assessment to ensure the child's condition does not worsen.
Choice D rationale: The pH value of 7.38 is within the normal range (7.35-7.45), indicating that the child is not experiencing acid-base imbalance. There is no immediate need to notify the healthcare provider about the pH value alone, as it does not suggest any critical condition requiring urgent intervention.
Choice E rationale: Preparing for immediate intubation due to elevated PaCO2 is not warranted. The child’s PaCO2 is 40, which is within the normal range for carbon dioxide levels (35-45 mmHg). Intubation is a severe intervention reserved for cases of respiratory failure, which is not indicated by the presented lab results.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
This is The correct answer.
RSV can survive on hard surfaces for several days and on hands for several hours.
Providing this information addresses the client's concern about the virus's survivability on surfaces.
Choice B rationale:
This statement is incorrect.
RSV can survive on hard surfaces for a longer duration than just several hours.
Providing this incorrect information could lead to misunderstandings about RSV transmission.
Choice C rationale:
This statement is incorrect.
RSV can survive on surfaces, so stating that it cannot survive outside of the body would be inaccurate and misleading.
Choice D rationale:
This statement is incorrect.
RSV can be transmitted not only through direct contact with an infected person but also through contact with contaminated surfaces and respiratory droplets.
Correct Answer is A
Explanation
Choice A rationale:
Your child may start to experience difficulty breathing.
This statement is accurate and crucial for the mother to be aware of.
RSV infections can progress to bronchiolitis or pneumonia, leading to more severe respiratory distress.
Difficulty breathing is a common symptom in these advanced stages of the infection, indicating the need for immediate medical attention.
Choice B rationale:
While a decreased appetite is a symptom mentioned in the scenario, it does not reflect the potential progression of RSV infection.
The focus should be on respiratory symptoms, which can indicate worsening conditions.
Choice C rationale:
Drowsiness is not a typical symptom of RSV progression.
Respiratory distress, such as difficulty breathing, is a more concerning sign and requires prompt medical evaluation.
Choice D rationale:
Developing a high fever is a general symptom of various infections, including RSV.
While fever is a concern, the scenario specifically mentions symptoms related to the respiratory system, making difficulty breathing a more relevant and specific warning sign for the mother to be aware of.
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