A nurse is assessing a 3-month-old child with RSV. The nurse identifies the following: HR of 140; RR of 32; Oxygen saturation is 89% on room air; inspiratory and expiratory wheezing of the upper lungs; temperature of 38
1 degrees Celsius; large amounts of thin secretions. Identify the priority at this time. 1. Administering acetaminophen to reduce the fever
2. Providing oxygen for the low saturation
3. Suctioning the nares and oropharnyx to remove the secretions
4. Providing a quiet environment
3
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1. The fever is low grade and not a priority at this time.
2. 89 percent oxygen saturation on room air needs to have a further assessment to see why the child is low in saturations.
3. Suctioning helps remove all the secretions and opens the airway with the possibility of increasing oxygen saturations.
4. A quiet environment will help the child rest, but is not a priority at this time.
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