RSV in children
RSV in children ( 14 Questions)
The nurse notes that the child’s respiratory rate is 35 breaths per minute, oxygen saturation is 96%, pH is 7.38, and PaCO2 is 40.
Which of the following actions should the nurse take based on these results? (Select all that apply).
Continuing to monitor the child’s respiratory rate is essential. The nurse should closely observe the child's respiratory status to detect any changes. Monitoring helps in assessing the effectiveness of interventions and identifying any worsening of the condition promptly.
Administering supplemental oxygen is appropriate in this situation because the child's oxygen saturation is 96%, which indicates that the child is not receiving adequate oxygen. Supplemental oxygen helps maintain appropriate oxygen levels and prevents hypoxia.
Reassessing the child’s oxygen saturation in one hour is a good nursing practice to ensure that the child's respiratory status remains stable or improves. Regular reassessment allows for timely adjustments in the treatment plan if needed.
While the pH value is within the normal range (7.35-7.45), it is essential to consider the entire clinical picture. The nurse should continue to monitor the child's respiratory status and other parameters. Notification to the healthcare provider may be necessary if there are significant changes in the child's condition, but the pH value alone does not warrant immediate notification.
Immediate intubation based solely on the elevated PaCO2 is not indicated. The child's PaCO2 of 40 mmHg falls within the normal range (35-45 mmHg) for a 3-year-old. Intubation is a significant intervention and should be considered based on the overall clinical assessment, including the child's respiratory distress, oxygen saturation, and other vital signs.
Choice A rationale:
Continuing to monitor the child’s respiratory rate is essential.
The nurse should closely observe the child's respiratory status to detect any changes.
Monitoring helps in assessing the effectiveness of interventions and identifying any worsening of the condition promptly.
Choice B rationale:
Administering supplemental oxygen is appropriate in this situation because the child's oxygen saturation is 96%, which indicates that the child is not receiving adequate oxygen.
Supplemental oxygen helps maintain appropriate oxygen levels and prevents hypoxia.
Choice C rationale:
Reassessing the child’s oxygen saturation in one hour is a good nursing practice to ensure that the child's respiratory status remains stable or improves.
Regular reassessment allows for timely adjustments in the treatment plan if needed.
Choice D rationale:
While the pH value is within the normal range (7.35-7.45), it is essential to consider the entire clinical picture.
The nurse should continue to monitor the child's respiratory status and other parameters.
Notification to the healthcare provider may be necessary if there are significant changes in the child's condition, but the pH value alone does not warrant immediate notification.
Choice E rationale:
Immediate intubation based solely on the elevated PaCO2 is not indicated.
The child's PaCO2 of 40 mmHg falls within the normal range (35-45 mmHg) for a 3-year-old.
Intubation is a significant intervention and should be considered based on the overall clinical assessment, including the child's respiratory distress, oxygen saturation, and other vital signs.