Respiratory Syncytial Virus Flashcards
A 10-week-old is brought to the emergency room with three days of rhinorrhea, congestion and cough. The mother feels the infant is in need of help breathing and states he has been unable to breast feed all day. Infant is exclusively breastfed. Older sibling is at home with respiratory illness as well.
Which of the following assessment findings require follow up by the nurse?
Heart rate of 178 beats per minute
Mild intercostal retractions
Capillary refill of 4 seconds
Intermittent wheezing bilaterally to both lungs
What should be included in teaching to reduce the risk of transmission of respiratory syncytial virus?
To reduce the risk of transmission of RSV, the nurse should emphasize to the parents and other visitors that touching surfaces within 3 feet of the infant can transmit the virus to their clothes and hands. Therefore, it is vital to help them understand how important it is to use protective gloves and gowns to avoid the spread and transmission of the organism—especially practicing good hand hygiene before entering the room and after removing the PPE, preventing the transmission to other individuals
A 10-week-old is brought to the emergency room with three days of rhinorrhea, congestion and cough. Mother feels the infant is in needs help breathing and states he has been unable to breast feed all day. Infant is exclusively breastfed. Older sibling is at home with respiratory illness as well.
Based on the infant’s assessment data, the nurse determines that the infant’s abnormal
vital sign findings are most likely due to Respiratory Distress and Dehydration .
Respiratory distress
Dehydration
Which of the following complications will the nurse anticipate when caring for this infant with bronchiolitis caused by respiratory syncytial virus?
Respiratory failure
Dehydration
Apnea
Hypoxemia
The 10-week-old client has an oxygen saturation of 92% on room air. Thick green secretions are noted in nares bilaterally. The priority action is oxygenation and nasal clearing for this client. Which of the following nursing interventions will help achieve these goals?
Normal saline for suctioning
Humidified oxygen
Nasal suctioning
Infants with nasal congestion are unable to clear their airway without assistance. Nasal suctioning with normal saline will help to clear the copious thick mucus with the least amount of trauma. To improve gas exchange, humidified oxygen should be applied to keep SPO2 at 95 %.
The infant is treated in the emergency department with nasal suctioning and blow by oxygen at 100%. Albuterol is given for wheezing with no effect. A chest x-ray is ordered. The infant improves slightly with a decrease in respiratory rate, but still has significant nasal congestion. Rapid laboratory testing for respiratory viral panel is pending with a probable diagnosis of bronchiolitis. The infant is admitted to the acute care unit for ongoing care.
Which of the following nursing interventions are indicated, contraindicated, or non-essential for this client?
Monitor vital signs and respiratory status every 1 to 2 hours.
Indicated
Conduct Nasopharyngeal suctioning every 4 hours
Contraindicated
Review Chest and X-ray results
Non-essential
Provide oxygen for O2 saturation less than 90% via HHFNC (heated, high-flow nasal cannula).
Indicated
Administer supplemental formula instead of breastmilk
Contraindicated
Several hours after being admitted to the acute care, the nurse finds the infant to have increased retractions, now including subclavicular, intercostal and subcostal retractions along with nasal flaring. The infant continues to have wheezing with a respiratory rate of 80 breaths/min, oxygen saturation of 86% on blow by oxygen and a temperature of 102.1 F. The infant appears dusky, fatigued, and slow to react.
Which of the following nursing actions would be included in the plan of care for this 10-week-old client with respiratory syncytial virus?
Position the infant’s head 30-40 degrees upright.
Administer antipyretics as prescribed.
Cluster care to promote rest periods.
Several hours after being admitted to the acute care, the nurse finds the infant to have increased retractions, now including subclavicular, intercostal and subcostal retractions along with nasal flaring. The infant continues to have wheezing with a respiratory rate of 80 breaths/min, oxygen saturation of 86% on blow by oxygen and a temperature of 102.1 F. The infant appears dusky, fatigued, and slow to react.
For each of the following assessment findings, indicate if the interventions have been effective, ineffective, or unrelated?
subclavicular, intercostal, and subcostal retractions with nasal flaring
Ineffective
Oxygen Saturation: 98% on 2L HHFNC
Effective
Infant is pink and responsive to stimulation
Effective
Sunken fontanels
Ineffective
Temperature of 100.7 degrees Fahrenheit
Effective
The client is discharged home but returns several days later with a high fever. The doctor suspects viral pneumonia. What should be included in the plan of care for this client?
The plan of care for this patient should include:
Positioning: Elevate the head of the bed and reposition every 2 hours to help with breathing and lung drainage. Older children can choose a comfortable position but must still change positions regularly. Avoid infant seats, as they can restrict lung expansion.
Breathing Support: Encourage coughing, deep breathing, and splinting to reduce discomfort. Humidified oxygen should be provided and monitored with pulse oximetry. A cardiorespiratory monitor may be used for children in respiratory distress.
Hydration: Oral or IV fluids are given as prescribed. IV fluids are used if oral intake is too stressful for the body. Monitor intake and output, check for dehydration signs (low urine output, poor skin turgor, dry mucous membranes, weight loss), and measure daily weight and urine specific gravity.
Energy Conservation: Plan rest periods to support oxygenation. Provide quiet activities (reading, puzzles, videos) and limit visitors, especially those with infections, to prevent additional illness.
Medication Management: Administer antipyretics, antibiotics, and analgesics as ordered. If the child experiences pain, notify the physician if no analgesic has been prescribed. Lying on the affected side may help relieve discomfort. Distraction techniques and adjusting the environment can also assist with pain relief.
Family Education & Support: Teach the child (if age-appropriate) and family about the disease and treatment. Encourage parental involvement in care, explain procedures, and offer emotional support. Educate the family on home care management to ensure a smooth transition after discharge.
Which of the following supports the diagnosis of viral pneumonia for this client?
White infiltrates on x-ray
