SAUNDERS respiratory

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3 year old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Definitive and requiring a repeat test

1. Positive

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care. Select all that apply. 1. Place the infant in a private room. 2. Ensure 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 on the side, with the head lower than the chest. 6. Ensure the nurses caring for the infant with RSV do not care for other high-risk children.

1. Place the infant in a private room. 6. Ensure the nurses caring for the infant with RSV do not care for other high-risk children.

A 10 year old child with asthma is treated for acute exacerbation in the ED. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm, dry skin 2. Decreased wheezing 3. Pulse rate of 90 beats/min 4. Respirations of 18 breaths/min

2. Decreased Wheezing Rationale: Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dark skin indicates an improvement in the child's condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/min. The normal RR n a 10 year old is 16 to 20 breaths/min

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1. Initiate strict enteric precautions 2. Move the infant to a room with another child with RSV. 3. Leave the infant in the present room because RSV is not contagious. 4. Inform the staff that the must wear a mask, gloves, and a gown when caring for the child.

2. Move the infant to a room with another child with RSV.

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? 1. The child exhibits nasal flaring and bradycardia. 2. The child is leaning forward, with the chin thrust out. 3. The child has a low grade fever and complains of a sore throat. 4. The child is leaning backward, supporting himself or herself with the hands and arms.

2. The child is leaning forward, with the chin thrust out

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup ) asks a nurse why the physician did not prescribe antibiotics. The appropriate response is: 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."

3. "Antibiotics are not indicated unless a bacterial infection is present."

The clinic nurse is providing instructions to a patient of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? 1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines." 3. "The child will receive all of the immunizations except for the polio series" 4. "The child will receive the recommended basic series of immunizations along with yearly influenza vaccination."

4. "The child will receive the recommended basic series of immunizations along with yearly influenza vaccination."

The mother of an 8 year old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and the ibuprofen is not effective. Which instruction should the nurse provide to the mother? 1. Increase the dose of ibuprofen 2. Increase the frequency of ibuprofen 3. Encourage the child to lie on the left side 4. Encourage the child to lie on the right side

4. Encourage the child to lie on the right side Rationale: Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on the side may decrease discomfort. It would be inappropriate to advise the mother to increase the dose or frequency of the ibuprofen. Lying on the left side would not be helpful in alleviating discomfort.

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? 1. Tell the mother that the child must stay in the tent. 2. Place a toy in the tent to make the child feel more comfortable. 3. Call the health care provider and obtain a prescription for a mild sedative. 4. Let the mother hold the child and direct the cool mist over the child's face

4. Let the mother hold the child and direct the cool mist over the child's face

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? 1. side or prone 2. back or prone 3. stomach with the face turned 4. back rather than on the stomach

4. back rather than on the stomach Rationale: SIDS is unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fail to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses should encourage parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffocation. The infant may have the ability to turn to a prone position from the side-lying position.