NU373 Week 3 HESI Case Study: Respiratory Syncytial Virus (RSV) Bronch
tis - 21 questions
Study online at https://quizlet.com/_aite5m
1. The client, a 6-week-old infant, is brought to o Continue respiratory assessment.
the emergency department (ED) by ambu-
lance, accompanied by a parent. The emer- · The nurse should complete the respi-
gency medical technician (EMT) reported to ratory assessment, as this will provide
the nurse that the client had a 2-day histo- important baseline information for the
ry of cold symptoms and became limp and healthcare provider (HCP).
cyanotic. The parent attempted cardiopul-
monary resuscitation (CPR), as instructed by
911. Upon arrival of the ambulance, the EMT
stabilized the client prior to transport to the
hospital. The nurse enters the room to find
the client crying in the parent's arms. The
nurse and the parent work together to calm
the client and then the nurse auscultates the
client's lungs. Coarse bilateral wheezes are
detected, but the client does not appear in
acute distress at this time.
What action should the nurse take next?
o Perform nasal suctioning.
o Continue respiratory assessment.
o Call the emergency response team.
o Document assessment findings.
2. Which techniques should the nurse use to o Place a pulse oximeter on a big toe of
assess for respiratory distress? Select all that the client's foot.
apply. · The nurse should use a pulse oxime-
ter to measure the client's oxygen satu-
o Place a pulse oximeter on a big toe of the ration level. A decreased oxygen satura-
, NU373 Week 3 HESI Case Study: Respiratory Syncytial Virus (RSV) Bronch
tis - 21 questions
Study online at https://quizlet.com/_aite5m
client's foot. tion level is a sign of respiratory compro-
o Inspect the chest wall for symmetry and mise. The foot is the preferred site for a
retractions. pulse oximeter because infants are apt to
o Percuss for hyperresonance. scratch themselves with the probe if it is
o Inspect oral mucosa for dryness. placed on the hand. Fingers are not used
o Count the client's pulse and respiratory because they are too small to support the
rates. probe. The infant's foot should be kept
warm, with a sock if necessary, to ensure
accurate measurement.
o Inspect the chest wall for symmetry and
retractions.
· Respiratory distress can be seen as an
asymmetrical chest wall expansion, inter-
costal retractions, and nasal flaring.
o Percuss for hyperresonance.
o Count the client's pulse and respiratory
rates.
· Tachycardia and tachypnea can both be
signs of respiratory distress.
3. The nurse continues the assessment. Which o Minimal response to stimuli.
assessment finding exhibited by the client
warrants immediate intervention by the · A change in the client's level of con-
nurse? sciousness is a significant indicator of
poor oxygenation and requires immedi-
o Rectal temperature of 100.0 °F (37.8 °C). ate intervention by the nurse.
o Capillary refill < 2 seconds.
o Minimal response to stimuli.
o Anterior fontanel is soft and flat.
tis - 21 questions
Study online at https://quizlet.com/_aite5m
1. The client, a 6-week-old infant, is brought to o Continue respiratory assessment.
the emergency department (ED) by ambu-
lance, accompanied by a parent. The emer- · The nurse should complete the respi-
gency medical technician (EMT) reported to ratory assessment, as this will provide
the nurse that the client had a 2-day histo- important baseline information for the
ry of cold symptoms and became limp and healthcare provider (HCP).
cyanotic. The parent attempted cardiopul-
monary resuscitation (CPR), as instructed by
911. Upon arrival of the ambulance, the EMT
stabilized the client prior to transport to the
hospital. The nurse enters the room to find
the client crying in the parent's arms. The
nurse and the parent work together to calm
the client and then the nurse auscultates the
client's lungs. Coarse bilateral wheezes are
detected, but the client does not appear in
acute distress at this time.
What action should the nurse take next?
o Perform nasal suctioning.
o Continue respiratory assessment.
o Call the emergency response team.
o Document assessment findings.
2. Which techniques should the nurse use to o Place a pulse oximeter on a big toe of
assess for respiratory distress? Select all that the client's foot.
apply. · The nurse should use a pulse oxime-
ter to measure the client's oxygen satu-
o Place a pulse oximeter on a big toe of the ration level. A decreased oxygen satura-
, NU373 Week 3 HESI Case Study: Respiratory Syncytial Virus (RSV) Bronch
tis - 21 questions
Study online at https://quizlet.com/_aite5m
client's foot. tion level is a sign of respiratory compro-
o Inspect the chest wall for symmetry and mise. The foot is the preferred site for a
retractions. pulse oximeter because infants are apt to
o Percuss for hyperresonance. scratch themselves with the probe if it is
o Inspect oral mucosa for dryness. placed on the hand. Fingers are not used
o Count the client's pulse and respiratory because they are too small to support the
rates. probe. The infant's foot should be kept
warm, with a sock if necessary, to ensure
accurate measurement.
o Inspect the chest wall for symmetry and
retractions.
· Respiratory distress can be seen as an
asymmetrical chest wall expansion, inter-
costal retractions, and nasal flaring.
o Percuss for hyperresonance.
o Count the client's pulse and respiratory
rates.
· Tachycardia and tachypnea can both be
signs of respiratory distress.
3. The nurse continues the assessment. Which o Minimal response to stimuli.
assessment finding exhibited by the client
warrants immediate intervention by the · A change in the client's level of con-
nurse? sciousness is a significant indicator of
poor oxygenation and requires immedi-
o Rectal temperature of 100.0 °F (37.8 °C). ate intervention by the nurse.
o Capillary refill < 2 seconds.
o Minimal response to stimuli.
o Anterior fontanel is soft and flat.
