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NurseDive Free Nursing Practice Question
A nurse is caring for a toddler who is hospitalized with respiratory syncytial virus (RSV). Which of the following nursing interventions is the priority?
A. Administer prescribed antipyretics for a temperature of 38.5°C (101.3°F)
Fever is a common symptom of RSV, and antipyretics can improve comfort. However, fever itself is not life-threatening and does not directly address the risk of airway compromise or hypoxia. Therefore, antipyretics are secondary to interventions that support breathing and oxygenation.
B. Encourage the child to drink small, frequent amounts of fluids
Hydration is important because RSV can cause poor oral intake, dehydration, and increased mucus viscosity, which may worsen airway obstruction. While promoting fluids is necessary, it is not as urgent as ensuring adequate oxygenation.
C. Monitor oxygen saturation and apply humidified oxygen if needed
Continuous monitoring of oxygen saturation allows for early detection of hypoxemia. Hypoxia can develop rapidly in infants and toddlers with RSV due to their smaller airway size and limited respiratory reserve. Humidified oxygen helps maintain airway moisture, reduces airway irritation, and supports gas exchange. Ensuring adequate oxygenation prevents complications such as respiratory failure, apnea, or cardiac compromise, making it the highest priority intervention.
D. Place the child on contact and droplet precautions
RSV is highly contagious and spreads via respiratory droplets and direct contact. Precautions are essential to protect staff and other patients, but infection control measures do not address the immediate threat to the patient’s respiratory status. Priority interventions must first ensure the child’s airway and oxygenation are stable.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Demsn 650 Pediatrics Proctored Exam. Take the full exam now
Full Explanation
A. Fever is a common symptom of RSV, and antipyretics can improve comfort. However, fever itself is not life-threatening and does not directly address the risk of airway compromise or hypoxia. Therefore, antipyretics are secondary to interventions that support breathing and oxygenation.
B. Hydration is important because RSV can cause poor oral intake, dehydration, and increased mucus viscosity, which may worsen airway obstruction. While promoting fluids is necessary, it is not as urgent as ensuring adequate oxygenation.
C. Continuous monitoring of oxygen saturation allows for early detection of hypoxemia. Hypoxia can develop rapidly in infants and toddlers with RSV due to their smaller airway size and limited respiratory reserve. Humidified oxygen helps maintain airway moisture, reduces airway irritation, and supports gas exchange. Ensuring adequate oxygenation prevents complications such as respiratory failure, apnea, or cardiac compromise, making it the highest priority intervention.
D. RSV is highly contagious and spreads via respiratory droplets and direct contact. Precautions are essential to protect staff and other patients, but infection control measures do not address the immediate threat to the patient’s respiratory status. Priority interventions must first ensure the child’s airway and oxygenation are stable.
Similar Questions
A 4-year-old child with a history of cystic fibrosis (CF) presents to the clinic for a routine follow-up. The parents report that the child has had an increase in productive cough, wheezing, and shortness of breath over the past few days. Upon examination, the child has clubbed fingers, and chest auscultation reveals decreased breath sounds. Given these findings, which of the following interventions should the nurse prioritize to manage the child's condition and prevent further respiratory complications?
A. Increasing the child's intake of high-fat foods to address malnutrition
Nutrition is important in CF because malabsorption is common, but addressing malnutrition is not the immediate priority when the child is experiencing respiratory compromise. Nutritional interventions are secondary to airway management.
B. Administering inhaled corticosteroids to reduce airway inflammation
Inhaled corticosteroids can help reduce chronic airway inflammation, but they do not remove existing mucus or immediately improve airflow. They are part of long-term management rather than urgent treatment during an exacerbation.
C. Initiating chest physiotherapy (CPT) to promote airway clearance and reduce mucus build-up
CPT is the cornerstone of CF management, particularly during exacerbations. Techniques such as percussion, postural drainage, and vibration help mobilize thick mucus, improve airway clearance, enhance oxygenation, and reduce the risk of infection and further lung damage. Immediate airway clearance is critical for symptom relief and prevention of respiratory complications.
D. Encouraging increased fluid intake to help with hydration and thin mucus
Adequate hydration can support mucus thinning but is not sufficient alone to manage an acute pulmonary exacerbation. It is adjunctive, supporting other interventions like CPT and medications.
Full Explanation
A. Nutrition is important in CF because malabsorption is common, but addressing malnutrition is not the immediate priority when the child is experiencing respiratory compromise. Nutritional interventions are secondary to airway management.
B. Inhaled corticosteroids can help reduce chronic airway inflammation, but they do not remove existing mucus or immediately improve airflow. They are part of long-term management rather than urgent treatment during an exacerbation.
C. CPT is the cornerstone of CF management, particularly during exacerbations. Techniques such as percussion, postural drainage, and vibration help mobilize thick mucus, improve airway clearance, enhance oxygenation, and reduce the risk of infection and further lung damage. Immediate airway clearance is critical for symptom relief and prevention of respiratory complications.
D. Adequate hydration can support mucus thinning but is not sufficient alone to manage an acute pulmonary exacerbation. It is adjunctive, supporting other interventions like CPT and medications.
Which of the following characteristics of the pediatric respiratory system makes infants and young children more susceptible to respiratory distress compared to adults?
A. Larger airway diameter and more developed lung volume
Infants actually have smaller airway diameters and less lung volume than adults. A larger airway and fully developed lungs would decrease susceptibility to respiratory compromise, not increase it.
B. Smaller airway diameter and immature respiratory muscles
Infants’ airways are narrow, so even minor swelling or mucus buildup can significantly obstruct airflow. Additionally, respiratory muscles, including the diaphragm and intercostals, are immature and fatigue easily, making it harder for infants to maintain adequate ventilation during illness or stress. These factors increase the risk of rapid respiratory compromise.
C. Larger alveolar surface area and stronger respiratory muscles
Infants have fewer alveoli and less surface area for gas exchange, and their respiratory muscles are weaker than adults, not stronger. This contributes to increased risk, not protection.
D. More developed diaphragm and increased lung compliance
The diaphragm is less developed in infants, and their chest wall is more compliant, which can lead to paradoxical movements and less effective ventilation. Increased diaphragm development and lung compliance would enhance respiratory function, not increase susceptibility.
Full Explanation
A. Infants actually have smaller airway diameters and less lung volume than adults. A larger airway and fully developed lungs would decrease susceptibility to respiratory compromise, not increase it.
B. Infants’ airways are narrow, so even minor swelling or mucus buildup can significantly obstruct airflow. Additionally, respiratory muscles, including the diaphragm and intercostals, are immature and fatigue easily, making it harder for infants to maintain adequate ventilation during illness or stress. These factors increase the risk of rapid respiratory compromise.
C. Infants have fewer alveoli and less surface area for gas exchange, and their respiratory muscles are weaker than adults, not stronger. This contributes to increased risk, not protection.
D. The diaphragm is less developed in infants, and their chest wall is more compliant, which can lead to paradoxical movements and less effective ventilation. Increased diaphragm development and lung compliance would enhance respiratory function, not increase susceptibility.
A 26-year-old pregnant woman at 26 weeks gestation is undergoing a 1-hour glucose challenge screening. She drinks the 50-gram glucose solution, and her blood glucose is measured 1 hour later at 150 mg/dL. Which of the following is the most appropriate next step?
A. Repeat the 1-hour test tomorrow
Repeating the screening test is not standard practice. A screening value above the threshold requires a diagnostic test, not a repeat screening.
B. Schedule a 3-hour oral glucose tolerance test for diagnostic confirmation
The 1-hour 50-gram glucose challenge is a screening test for gestational diabetes mellitus (GDM). A blood glucose level of ≥140 mg/dL (some guidelines use 130 mg/dL) indicates a positive screen. The next step is a 3-hour, 100-gram OGTT, which is the diagnostic test to confirm or rule out GDM.
C. Begin insulin therapy immediately
Initiating insulin therapy is premature. Diagnosis of GDM requires confirmation by the 3-hour OGTT. Treatment decisions, including diet, exercise, or insulin therapy, are based on confirmed diagnosis and blood glucose patterns.
D. Reassure the patient that the result is normal; no further testing is needed
A 1-hour glucose level of 150 mg/dL exceeds the normal screening threshold, so further diagnostic testing is required. Reassuring without follow-up could miss a diagnosis of GDM, increasing maternal and fetal risks.
Full Explanation
A. Repeating the screening test is not standard practice. A screening value above the threshold requires a diagnostic test, not a repeat screening.
B. The 1-hour 50-gram glucose challenge is a screening test for gestational diabetes mellitus (GDM). A blood glucose level of ≥140 mg/dL (some guidelines use 130 mg/dL) indicates a positive screen. The next step is a 3-hour, 100-gram OGTT, which is the diagnostic test to confirm or rule out GDM.
C. Initiating insulin therapy is premature. Diagnosis of GDM requires confirmation by the 3-hour OGTT. Treatment decisions, including diet, exercise, or insulin therapy, are based on confirmed diagnosis and blood glucose patterns.
D. A 1-hour glucose level of 150 mg/dL exceeds the normal screening threshold, so further diagnostic testing is required. Reassuring without follow-up could miss a diagnosis of GDM, increasing maternal and fetal risks.