During the assessment of a young child admitted with possible respiratory syncytial virus (RSV) bronchiolitis, the nurse observes the child grunting with expiration. Which of the following should the nurse do to assist this child?
1. Suction the airway to relieve the obstruction
2. Lay the child on his back
3. Limit fluids
4. Assist the child to clear the nasal passages
1. Suction the airway to relieve the obstruction
Rationale:
Grunting is seen with partial airway obstruction caused by increased secretions and edema. The nurse should suction the airway to relieve the obstruction. Laying the child on his back will not improve the child's ability to breath. Fluids should be increased to thin secretions. Assisting the child to clear the nasal passages would be applicable if the child were experiencing rhinorrhea.
You might also like to view...
An elderly patient has begun taking bisoprolol (Zebeta) 10 mg PO once daily for the treatment of angina. The nurse should administer this drug in the knowledge that it achieves a therapeutic effect in what way?
A) Decreasing heart rate B) Increasing the force of myocardial contractions C) Prolonging the QT interval D) Shortening the time required for repolarization
During a sports physical, a client is found to have myopia, long digits, tall stature, an arm span greater than his height, scoliosis, and a hollow chest. The nurse should suspect:
1. Phenylketonuria. 2. Turner's syndrome. 3. Huntington's chorea. 4. Marfan's syndrome.
A client has a history of drug use and is screened for hepatitis B during the first trimester. Which action is appropriate?
a. Practice respiratory isolation. b. Plan for retesting during the third trimester. c. Discuss the recommendation to bottle feed her baby. d. Anticipate administering the vaccination for hepatitis B as soon as possible.
A nurse resigns from a position in a hospital to accept a job in a community setting. After starting the new job, the nurse feels helpless and confused, wondering if this was the right career choice. This nurse is likely experiencing cultural
a. Conflict b. Relativism c. Shock d. Brokering