The nurse is caring for a 10-month-old infant diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the child's care? (Select all that apply.).
Institute cluster care to encourage adequate rest.
Administer cough syrup.
Administer antibiotics.
Encourage infant to drink 8 ounces of formula every 4 hours.
Place on noninvasive oxygen monitoring.
Correct Answer : A,E
The correct answers are choices A and E: Institute cluster care to encourage adequate rest and Place on noninvasive oxygen monitoring.
Choice A rationale:
Institute cluster care to encourage adequate rest. This is a correct choice. Cluster care involves grouping nursing interventions together to minimize disruptions to the child's rest. Adequate rest is crucial for the healing process in infants with respiratory syncytial virus (RSV) bronchiolitis.
Choice B rationale:
Administer cough syrup. This choice is incorrect for RSV bronchiolitis. Cough syrup is not recommended for infants with bronchiolitis. RSV primarily affects the lower respiratory tract and can cause airway inflammation, making cough syrup potentially ineffective and unnecessary.
Choice C rationale:
Administer antibiotics. This choice is incorrect for RSV bronchiolitis. RSV is a viral infection, and antibiotics are ineffective against viruses. Antibiotics should only be used when there is a bacterial infection or a clear indication.
Choice D rationale:
Encourage infant to drink 8 ounces of formula every 4 hours. This choice is not the best approach for managing RSV bronchiolitis. Infants with RSV may experience decreased appetite due to respiratory distress. Smaller, more frequent feedings are often recommended to prevent overfeeding and aspiration.
Choice E rationale:
Place on noninvasive oxygen monitoring. This is a correct choice. RSV bronchiolitis can cause respiratory distress and compromise oxygenation. Noninvasive oxygen monitoring helps assess the child's oxygen levels and aids in determining the need for supplemental oxygen therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Cardiac valve damage.
Choice A rationale:
Pulmonary hypertension is not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart, joints, skin, and brain, and pulmonary hypertension is not a typical manifestation of this condition.
Choice B rationale:
Cardiac valve damage is a common and serious complication of rheumatic fever. Rheumatic fever is caused by an autoimmune reaction to untreated streptococcal infections, particularly Streptococcus pyogenes. The immune response targets not only the streptococcal bacteria but also the body's own tissues, especially heart valves. This can lead to inflammation of the heart valves, a condition known as rheumatic heart disease. Over time, repeated bouts of rheumatic fever can result in significant damage to the heart valves, leading to valve insufficiency or stenosis. This can ultimately cause heart failure and other cardiovascular complications.
Choice C rationale:
Seizures are not a common complication of rheumatic fever. Rheumatic fever primarily affects the heart and other body systems, but it does not typically lead to seizures.
Choice D rationale:
Cardiac arrhythmias are possible complications of rheumatic fever, but they are not as common or significant as cardiac valve damage. The inflammation and scarring caused by rheumatic fever can disrupt the electrical pathways of the heart, potentially leading to arrhythmias. However, the more prevalent and severe consequence of rheumatic fever is the damage to the heart valves.
Correct Answer is C
Explanation
The correct answer is choice C. After taking antibiotics for 24 hours.
Choice A rationale:
Returning to school if no complications develop is not a sufficient guideline for allowing a child with streptococcal pharyngitis to return to school. Streptococcal pharyngitis (strep throat) is highly contagious, and children should be treated with antibiotics to prevent the spread of the infection.
Choice B rationale:
Waiting until the sore throat is better is not a specific enough criterion for returning to school. While the resolution of symptoms is an important factor, it's crucial to ensure that the child has also been on antibiotics for an appropriate duration to reduce the risk of spreading the infection to others.
Choice C rationale:
The recommended guideline is to return to school after taking antibiotics for 24 hours. This timeframe helps ensure that the child's contagiousness is significantly reduced, minimizing the risk of transmitting the infection to classmates and school staff.
Choice D rationale:
Waiting for three days after taking antibiotics is not as precise as waiting for 24 hours. With proper antibiotic treatment, the child's contagiousness decreases rapidly, and waiting for three days might be unnecessary and could potentially result in more missed school days than needed.
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