Approach,2nd Edition (Tagher, 2024), Chapter 1-34 | All
Chapters
Chapter 1: Bronchiolitis
1. Which intervention is appropriate for the infant hospitalized with bronchiolitis?
a. Position on the side with neck slightly flexed.
b. Administer antibiotics as ordered.
c. Restrict oral and parenteral fluids if tachypneic.
d. Give cool, humidified oxygen. ANS: D
Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from
c. Contact Precautions
d. Standard Precautions 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.
3. A child has a chronic cough and diffuse wheezing during the expiratory phase of respiration. This
suggests what condition?
a. Asthma
b. Pneumonia
c. Bronchiolitis
d. Foreign body in trachea ANS: A
d. Tissue Perfusion, Ineffective (peripheral) ANS. A
Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply and
demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually
associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory -
disease process.
Rationale 2: Activity intolerance is a problem because of the imbalance between oxygen supply and
demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually
associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by th is respiratory-
disease process.
,Rationale 3: Activity intolerance is a problem because of the imbalance between oxygen supply and
demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually
associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory -
disease process.
Rationale 4: Activity intolerance is a problem because of the imbalance between oxygen supply and
demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually
associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory -
disease process.
Global Rationale: Activity intolerance is a problem because of the imbalance between oxygen supply and
demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually
associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-
disease process.
c. Bradycardia
d. Clubbing ANS: A
The nurse would assess the child for signs of hypoxia, including restlessness, fatigue, irritability, and
increased heart and respiratory rate. As the child tires from the increased work of breathing
hypoventilation occurs leading to increased carbon dioxide levels. The nurse would be alert for signs of
, hypoxia. Thirst would reflect the childs hydration status. Bradycardia is not a sign of hypoxia; tachycardia
is. Clubbing develops over a period of months in response to hypoxia. The presence of clubbing does not
indicate the childs condition is worsening.
2. Which finding is expected when assessing a child hospitalized for asthma?
a. Inspiratory stridor
b. Harsh, barky cough
c. Wheezing
b. Bronchitis
c. Asthma
d. Sinusitis ANS: D
Sinusitis is characterized by signs and symptoms of a cold that do not improve after 14 days, a