Respiratory Syncytial Virus (RSV)
Bronchiolitis HESI CASE
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What action should the nurse take next? - CORRECT ANSWERS-Continue respiratory
assessment.
The nurse should complete the respiratory assessment, as this will provide important
baseline information for the healthcare provider (HCP).
Which techniques should the nurse use to assess for respiratory distress? - CORRECT
ANSWERS-Place a pulse oximeter on a big toe of the baby's foot.
The nurse should use a pulse oximeter to measure the infant's oxygen saturation level.
A decreased oxygen saturation level is a sign of respiratory compromise. The foot is the
preferred site for a pulse oximeter because infants are apt to scratch themselves with
the probe if it is placed on the hand. Fingers are not used because they are too small to
support the probe. The infant's foot should be kept warm, with a sock if necessary, to
ensure accurate measurement.
Inspect the chest wall for symmetry and retractions.
Respiratory distress can be seen as an asymmetrical chest wall expansion, intercostal
retractions, and nasal flaring.
Count the infant's pulse and respiratory rates.
Tachycardia and tachypnea can both be signs of respiratory distress.
The nurse continues the assessment. Which assessment finding exhibited by Emma
warrants immediate intervention by the nurse? - CORRECT ANSWERS-minimal
response to stimuli
- A change in the infant's level of consciousness is a significant indicator of poor
oxygenation and requires immediate intervention by the nurse.
A nursing student is precepting with Emma's primary nurse. The nurse asks the student
about signs and symptoms of respiratory distress. Which findings should the nurse
confirm is a sign of worsening shortness of breath for the client? - CORRECT
ANSWERS-Nasal flaring.
Nasal flaring is sign of respiratory distress in the pediatric client.
Restlessness.
Restlessness is an early sign of respiratory distress in the pediatric client.
, Retractions.
This is a sign of respiratory distress in the pediatric client.
Emma is having some increasing respiratory distress. The nurse notes that Emma is
nasal flaring and she is having substernal retractions. The nurse suctions her mouth
and nasal passages with a bulb syringe to clear secretions and emergency blow-by
oxygen is given. Emma is now responding to Susan's voice. Susan attempts to bottle
feed Emma. The nurse observes that the infant has difficulty sucking and keeps spitting
out the nipple. The nurse notes that Emma still has thick nasal secretions and that her
respiratory rate has increased to 50 breaths per minute with her sucking effort.
Which action should the nurse take? - CORRECT ANSWERS-Suction the infant's nose
again.
Due to the posterior soft palate covering the oropharynx and the tongue's close
proximity with the hard and soft palate, infants this age are obligate nose breathers.
When the nose is congested they cannot form a seal to suck. Consequently, their
respiratory effort increases as they attempt to breathe through congested nasal
passages and suck at the same time.
Soon after, the HCP evaluates Emma and determines that she has respiratory syncytial
virus (RSV) prescribes the following: NPO status, IV fluids, Ventolin (albuterol) aerosol,
diphenhydramine (Benadryl) 0.5 mg/kg every 8 hours PO, oxygen set to 1/2 liter per
nasal cannula, and nasal suction with normal saline prn.
Additionally, the HCP prescribes 5% dextrose and one-half normal saline with 20 mEq
potassium chloride at 100 mL per kg over 24 hrs. Emma weighs 12 pounds. -
CORRECT ANSWERS-23
Convert weight in pounds to kilograms and multiple by 100 mL; then divide by 24 hours
for hourly flow rate. 12 lbs /2.2 kg = 5.45 kg × 100 mL ÷ 24 hours = 22.7 mL/hour. 23 mL
per hour is acceptable.
After the client has had many unsuccessful IV attempts, the IV therapy team is called,
and they decide to start the IV in the infant's scalp. What should the nurse do next to
best promote atraumatic care and to get the IV in place in a timely fashion? -
CORRECT ANSWERS-Give the infant sucrose solution (Sweet Ease) on a nipple to
suck during the procedure.
It has been shown that an infant sucking during painful, invasive procedures reduces
pain. The use of a sucrose solution (Sweet Ease) also reduces the painful experience
for the infant and is the most atraumatic intervention.
The IV line is placed successfully in a peripheral vein in the right lateral side of the scalp
and secured with a tegaderm adhesive and tape. The nurse assesses that the IV
flushes well and is patent. Which would the nurse expect to see if the IV infiltrated?
(Select all the apply.) - CORRECT ANSWERS-Swelling.
Swelling will be noted with an infiltrated IV.
Bronchiolitis HESI CASE
STUDY:Latest Questions With
Verified Answers||A+ Guarantee!!
What action should the nurse take next? - CORRECT ANSWERS-Continue respiratory
assessment.
The nurse should complete the respiratory assessment, as this will provide important
baseline information for the healthcare provider (HCP).
Which techniques should the nurse use to assess for respiratory distress? - CORRECT
ANSWERS-Place a pulse oximeter on a big toe of the baby's foot.
The nurse should use a pulse oximeter to measure the infant's oxygen saturation level.
A decreased oxygen saturation level is a sign of respiratory compromise. The foot is the
preferred site for a pulse oximeter because infants are apt to scratch themselves with
the probe if it is placed on the hand. Fingers are not used because they are too small to
support the probe. The infant's foot should be kept warm, with a sock if necessary, to
ensure accurate measurement.
Inspect the chest wall for symmetry and retractions.
Respiratory distress can be seen as an asymmetrical chest wall expansion, intercostal
retractions, and nasal flaring.
Count the infant's pulse and respiratory rates.
Tachycardia and tachypnea can both be signs of respiratory distress.
The nurse continues the assessment. Which assessment finding exhibited by Emma
warrants immediate intervention by the nurse? - CORRECT ANSWERS-minimal
response to stimuli
- A change in the infant's level of consciousness is a significant indicator of poor
oxygenation and requires immediate intervention by the nurse.
A nursing student is precepting with Emma's primary nurse. The nurse asks the student
about signs and symptoms of respiratory distress. Which findings should the nurse
confirm is a sign of worsening shortness of breath for the client? - CORRECT
ANSWERS-Nasal flaring.
Nasal flaring is sign of respiratory distress in the pediatric client.
Restlessness.
Restlessness is an early sign of respiratory distress in the pediatric client.
, Retractions.
This is a sign of respiratory distress in the pediatric client.
Emma is having some increasing respiratory distress. The nurse notes that Emma is
nasal flaring and she is having substernal retractions. The nurse suctions her mouth
and nasal passages with a bulb syringe to clear secretions and emergency blow-by
oxygen is given. Emma is now responding to Susan's voice. Susan attempts to bottle
feed Emma. The nurse observes that the infant has difficulty sucking and keeps spitting
out the nipple. The nurse notes that Emma still has thick nasal secretions and that her
respiratory rate has increased to 50 breaths per minute with her sucking effort.
Which action should the nurse take? - CORRECT ANSWERS-Suction the infant's nose
again.
Due to the posterior soft palate covering the oropharynx and the tongue's close
proximity with the hard and soft palate, infants this age are obligate nose breathers.
When the nose is congested they cannot form a seal to suck. Consequently, their
respiratory effort increases as they attempt to breathe through congested nasal
passages and suck at the same time.
Soon after, the HCP evaluates Emma and determines that she has respiratory syncytial
virus (RSV) prescribes the following: NPO status, IV fluids, Ventolin (albuterol) aerosol,
diphenhydramine (Benadryl) 0.5 mg/kg every 8 hours PO, oxygen set to 1/2 liter per
nasal cannula, and nasal suction with normal saline prn.
Additionally, the HCP prescribes 5% dextrose and one-half normal saline with 20 mEq
potassium chloride at 100 mL per kg over 24 hrs. Emma weighs 12 pounds. -
CORRECT ANSWERS-23
Convert weight in pounds to kilograms and multiple by 100 mL; then divide by 24 hours
for hourly flow rate. 12 lbs /2.2 kg = 5.45 kg × 100 mL ÷ 24 hours = 22.7 mL/hour. 23 mL
per hour is acceptable.
After the client has had many unsuccessful IV attempts, the IV therapy team is called,
and they decide to start the IV in the infant's scalp. What should the nurse do next to
best promote atraumatic care and to get the IV in place in a timely fashion? -
CORRECT ANSWERS-Give the infant sucrose solution (Sweet Ease) on a nipple to
suck during the procedure.
It has been shown that an infant sucking during painful, invasive procedures reduces
pain. The use of a sucrose solution (Sweet Ease) also reduces the painful experience
for the infant and is the most atraumatic intervention.
The IV line is placed successfully in a peripheral vein in the right lateral side of the scalp
and secured with a tegaderm adhesive and tape. The nurse assesses that the IV
flushes well and is patent. Which would the nurse expect to see if the IV infiltrated?
(Select all the apply.) - CORRECT ANSWERS-Swelling.
Swelling will be noted with an infiltrated IV.
