Respiratory Syncytial Virus (RSV) Bronchiolitis HESI CASE STUDY: questions and answers graded A+

Respiratory Syncytial Virus (RSV) Bronchiolitis HESI CASE STUDY: questions and answers graded A+ What action should the nurse take next? - 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? - 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? - 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? - 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 not