Question: A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse include in the plan of care? Select all that apply.
1. Place the infant in a private room.
2. Ensure that the infant's head is in a flexed position.
3. Wear a mask at all times when in contact with the infant.
4. Place the infant in a tent that delivers warm humidified air.
5. Position the infant side-lying, with the head lower than the chest.
6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
Answer: 1, 6
Rationale: Respiratory syncytial virus (RSV) is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care (wearing gloves and a gown) reduce nosocomial transmission of RSV. A mask is unnecessary. Additionally, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.
Test-Taking Strategy: Recalling the mode of transmission of RSV will assist in determining that the infant needs to be placed in a private room or in a room with another infant with RSV infection and that contact precautions need to be maintained. Recalling the need to maintain a patent airway (edema and the accumulation of mucus obstruct the bronchioles) will assist in determining that the infant needs to be observed closely, the infant's head should be elevated, and the infant should receive cool humidified oxygen. Review care of a child with bronchiolitis and RSV if you had difficulty with this question.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Child Health—Eye/Ear/Throat/Respiratory/Cardiovascular
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd ed., pp. 1187, 1193). St. Louis: Saunders.
This week’s NCLEX exam practice question came from:
Silvestri: Saunders Comprehensive Review for the NCLEX-RN Examination, 5th Edition, Chapter 38, Page 452, Question 396
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