Which nursing diagnosis is most appropriate for an infant with ...

[karlynnae]

Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)?
 
  1. Activity Intolerance
  2. Decreased Cardiac Output
  3. Pain, Acute
  4. Tissue Perfusion, Ineffective (peripheral)

Question 2

A child is admitted to the hospital with pneumonia. The child's oximetry reading is 88 percent upon admission to the pediatric floor. Which is the priority nursing intervention for this child?
 
  1. Obtain a blood sample to send to the lab for electrolyte analysis.
  2. Begin oxygen per nasal cannula.
  3. Medicate for pain.
  4. Begin administration of intravenous fluids.

[kjohnson]

Answer to Question 1

Correct Answer: 1
Rationale: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Answer to Question 2

Correct Answer: 2
Rationale: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child's oxygenation status has been addressed.

[karlynnae]

Excellent

[Kedrick2014]

Gracias!