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 ["A","B","D"]
Explanation
The correct answers are choices A, B, and D.
Choice A rationale:
Applying petroleum jelly to the suture line is a necessary intervention in an infant's postoperative plan of care following cleft lip repair. Petroleum jelly helps to keep the suture line moist and prevents it from sticking to clothing or linens. This promotes proper healing and reduces the risk of trauma to the surgical site.
Choice B rationale:
Using elbow restraints is important to prevent the infant from accidentally touching or scratching the surgical site. Infants are not always able to control their movements effectively, and they may inadvertently disrupt the healing process by touching the suture line. Elbow restraints help maintain the integrity of the surgical site.
Choice C rationale:
While positioning is important in the care of a postoperative infant, supine and side-lying positions are not specific interventions related to cleft lip repair. These positions may be used for general comfort and to prevent complications such as aspiration, but they are not directly related to the surgical site.
Choice D rationale:
Mouth irrigations are not typically recommended in the postoperative care of an infant following cleft lip repair. The surgical site is in the area of the lip, not the mouth, so mouth irrigations are not directly relevant to this procedure.
Choice E rationale:
Postural drainage is not a necessary intervention for an infant following cleft lip repair. Postural drainage is a technique used to help clear mucus and secretions from the lungs in patients with respiratory conditions. It is not applicable to the care of an infant recovering from cleft lip surgery.
Correct Answer is C
Explanation
The correct answer is choice C: Concrete operations stage.
Choice A rationale:
The preoperational stage, which occurs roughly between ages 2 and 7, is characterized by egocentrism, animism, and a lack of conservation. Children in this stage struggle with understanding that quantities can remain the same even if their appearance changes. For instance, they might think that pouring water from a tall glass into a short, wide glass somehow changes the amount of water. This stage does not demonstrate the mental understanding required for the examples given in the question.
Choice B rationale:
The intuitive thought stage, which typically spans from ages 4 to 7, is marked by increased symbolic thinking but still lacks the capacity for logical and systematic reasoning. Children in this stage might be able to count and perform basic arithmetic, but they struggle with more complex operations and understanding the underlying principles of mathematical operations. This stage is not where the ability to understand the given math operations is firmly established.
Choice C rationale:
The concrete operations stage, which encompasses ages 7 to 11, is characterized by the development of logical and systematic thinking. Children in this stage are capable of understanding basic mathematical principles and operations, such as conservation of quantity and simple arithmetic. They can mentally manipulate numbers and understand that reversing an operation will yield the original quantity. Therefore, this stage is when the ability to understand that 1 + 3 = 4 and 4 - 3 = 1 occurs.
Choice D rationale:
The formal operations stage, typically beginning around age 11, is characterized by abstract and hypothetical thinking. This is when adolescents and adults can engage in complex reasoning and consider multiple possibilities and outcomes. The given math operations are not the focus of this stage; rather, it pertains to more advanced cognitive abilities like hypothetical problem-solving and deductive reasoning.
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