2 Respiratory Syncytial Virus (RSV) HESI RN CASE STUDY

2 Respiratory Syncytial Virus (RSV) HESI RN CASE STUDY-When the nurse enters the room, she finds Emma crying in her mother's arms. The nurse and Susan calm Emma, 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: 71 What action should the nurse take next? A. Perform nasal suctioning. B. Continue respiratory assessment. Correct C. Call the emergency response team. D. Document assessment findings. Awarded 1.0 points out of 1.0 possible points. 3. 2.ID: 63 Which techniques 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 B. Inspect the chest wall for symmetry and retractions. Correct C. Percuss for hyperresonance. D. Inspect oral mucosa for dryness. E. Count the infant’s pulse and respiratory rates. Correct Tachycardia and tachypnea can both be signs of respiratory distress. Awarded 1.0 points out of 1.0 possible points. 4. 3.ID: 53 The nurse continues the assessment. Which assessment finding exhibited by Emma warrants immediate intervention by the nurse? A. Rectal temperature of 100.0° F (37.8° C). B. Capillary refill 2 seconds. C. Minimal response to stimuli. Correct D. Anterior fontanel is soft and flat. This is a normal finding in an infant this age. Awarded 1.0 points out of 1.0 possible points. 5. 4.ID: 75 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? (Select all that apply.) A. Nasal flaring. Correct Nasal flaring is sign of respiratory distress in the pediatric client. B. Restlessness. Correct C. Oxygen saturation level of 98%. D. Respiratory rate of 30 breaths per minute. For the client's age, this is an acceptable respiratory rate. E. Retractions. Correct This is a sign of respiratory distress in the pediatric client. Awarded 1.0 points out of 1.0 possible points. 6. 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. 7. 5.ID: 69 Which action should the nurse take? A. Cut a bigger hole in the nipple.