HESI CASE –RSV – Flashcards

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