NCLEX RDS, Bronchiolitis (RSV), Bronchopulmonary dysplasia actual questions and answers solved 100%
A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care. Select all that apply. Ans ✔✔- 1. Place the infant in a private room.
2. Place the infant in a room near the nurses' station.
3. Ensure that the infant's head is in a flexed position.
4. Wear a mask at all times when in contact with the infant.
5. Place the child in a tent that delivers warm, humidified air.
6. Position the infant side-lying, with the head lower than the chest.
Rationale: The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended
to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions
(wearing gloves and a gown) reduce the nosocomial transmission of RSV.
A nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which of the following would be the appropriate nursing action? Ans ✔✔- 1. Initiate strict enteric precautions.
2. Wear a mask when caring for the child.
3. Plan to move the infant to a room with another child with RSV.
4. Leave the infant in the present room, because RSV is not contagious.
Rationale: RSV is a highly communicable disorder, but it is not transmitted via the airborne route. It is usually transferred by the hands, and meticulous handwashing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary; however, the nurse should wear a gown when the soiling of clothing may occur. An infant with bronchiolitis is hospitalized. The causative organism is respiratory syncytial virus (RSV). The nurse knows that a child infected with this virus requires the following isolation: a. reverse isolation.
b. airborne isolation.
c. Contact Precautions.
d. Standard Precautions. Ans ✔✔- ANS: C
RSV is transmitted through droplets. In addition to Standard Precautions and hand washing, Contact Precautions are required. Caregivers must use gloves and gowns when entering the room. Care is taken not to touch their own eyes or mucous membranes with a contaminated gloved hand. Children are placed in a private room or in a room with other children with RSV infections. Reverse isolation focuses on keeping bacteria away from the infant. With RSV, other children need to be protected from exposure to the virus. The virus is not airborne.
16. An infant is hospitalized with RSV bronchiolitis. The priority nursing diagnosis is:
a. fatigue related to increased work of breathing. b. ineffective breathing pattern related to airway inflammation and increased secretions. c. risk for fluid volume deficit related to tachypnea and decreased oral intake. d. fear and/or anxiety related to dyspnea and hospitalization. Ans ✔✔- ANS: B
An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.
5. The nurse auscultating breath sounds of an infant with respiratory syncytial virus would immediately report the assessment of:
a. respiration rate decrease from 40 to 32 breaths/min. b. heart rate decrease from 110 to 100 beats/min. c. "quiet chest" from previous assessment of wheezing. d. oxygen saturation of 90%. Ans ✔✔- ANS: C
A "quiet chest" after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration.
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