NURS 649 Pediatrics-Respiratory Syncytial Virus HESI *A+ Guide*

Respiratory Syncytial Virus (RSV) Bronchiolitis Page 1 When the nurse enters the room she finds Grace crying in her mother's arms. The nurse and Wendy calm Grace, and then the nurse auscultates the infant's lungs. Coarse bilateral wheezes are detected, but the infant does not appear in acute distress at this time. 2. 1.ID: 0 What action should the nurse take next? A. Perform nasal suctioning. Document assessment findings. Awarded 1.0 points out of 1.0 possible points. 3. 2.ID: 3 What technique(s) should the nurse use to assess for respiratory distress? (Select all that apply.) A. Place a pulse oximeter on a big toe of the baby’s foot. Correct Percuss for hyperresonance. D. Inspect oral mucosa for dryness. E. Count the infant’s pulse and respiratory rates. Correct Awarded 1.0 points out of 1.0 possible points. 4. The nurse continues the assessment. 5. 3.ID: 4 Which assessment finding exhibited by Grace warrants immediate intervention by the nurse? A. Rectal temperature of 100.0° F. B. Dry mucous membranes. C. Minimal response to stimuli. Correct