HESI CASE –RSV – Flashcards
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What action should the nurse take
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continue respiratory assessment
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what techniques should the nurse use to assess for respiratory distress?
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-Inspect on chest wall for symmetry and retractions -Count the infants pulse/respiratory rates -place pulse ox on big toe of infant
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Which assessment finding exhibited by Grace warrents Immediate intervention by nurse?
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minimal response to stimuli
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What action should the nurse take?
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Suction nose agian
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How many ml/hr will nurse set IV pump for??
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23
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What should the nurse do next to best promote atramatic care...
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Infant sucrose solution (sweet Ease) on a nipple to suck on during procedure.
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what action should the nurse take?
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Apply @ 1/2 liter nasel cannula as prescribed
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Which med should the nurse question?
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Diphenhydramine (Benadryl)
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what nursing dx has the highest priority?
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Ineffective airway clearance
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which staff member should Charge nurse assign to Grace for the day?
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RN, w/ 9m old (pneumonia)
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which staff will transport child to peds unit?
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experienced Ped RN, floated to ER for day.
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what statement by the nurse reflects the philosophy of family centered care
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while you hold Grace, we can talk about her diagnosis and care
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What action should nurse take?
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-Rapid response -reposition -notify the HCP
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What type of precautions should PICU nurse initiate while Grace receives ribavirin
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restrict pregnant care givers
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what type of toy should nurse recommend
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musical mobile
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After gathering exam gloves and bulb syringe, the nurse should include
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Nasal Saline Drops
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How should the nurse respond?
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the amount of mucous is not as important as how she acts after the treatment
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How should the nurse respond?
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use proper hand hygiene and stay away from the sick
