Author Question: Which of the following assessment findings would indicate that interventions provided for a client ... (Read 42 times)

notis · **on:** Jul 22, 2018

Which of the following assessment findings would indicate that interventions provided for a client with respiratory syncytial virus (RSV) bronchiolitis have been effective?

1. Client resting in bed with limited interest in play activities
2. Client ingesting small amounts of clear fluids when encouraged
3. Client respiratory rate within normal limits for age
4. Client coughing copious amounts of green sputum and requires occasional suctioning

Question 2

The nurse is planning care for a child with respiratory syncytial virus (RSV) bronchiolitis with Impaired Gas Exchange. Which of the following should be included in this client's plan of care?

1. Monitor vital signs and pulse oximetry
2. Weigh daily
3. Weigh diapers
4. Provide frequent rest periods

popopong · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

3. Client respiratory rate within normal limits for age

Rationale:
Evidence that care is effective would include normal rate, rhythm, and quality of the breathing patterns for the client's age. The client who is resting in bed with limited interest in play is not demonstrating an improvement in respiratory status. The client who is ingesting small amounts of fluids might still be experiencing thickened secretions. If the client is coughing copious amounts of green sputum and requiring occasional suctioning, the interventions have not been effective since the child still needs assistance with clearing the airway.

Answer to Question 2

1. Monitor vital signs and pulse oximetry

Rationale:
Interventions appropriate for the client with Impaired Gas Exchange due to RSV bronchiolitis include monitoring vital signs, pulse oximetry, breathing pattern, and administer oxygen. Daily weight would be appropriate for the diagnosis of Impaired Nutrition: Less than Body Requirements. Weighing diapers would be appropriate for the diagnosis of Fluid Volume Deficit. Providing frequent rest periods would be appropriate for the diagnosis of Activity Intolerance.