ASSESSMENT & VS
What are Maria’s abnormal vital signs on admission and what do they indicate?
What is HR 140, RR 42, O2 Sat 90%, T 101.2°F → Indicates respiratory distress, possible infection, and hypoxia?
What PPE is required for RSV and why?
Gown, gloves, and mask (droplet + contact precautions).
Why is albuterol used in RSV treatment?
To reduce bronchospasm and improve airflow, especially if wheezing is present.
Why use a medical interpreter with Sara?
Ensures accurate communication, informed consent, and patient safety.
What is SBAR and why is it used?
Situation, Background, Assessment, Recommendation → Ensures structured, clear communication.
What is the significance of circumoral cyanosis when crying?
What is suggests oxygen desaturation during increased respiratory effort
Name two types of isolation needed for Maria?
Droplet and contact; prevents viral spread via secretions and surfaces
What’s Maria’s albuterol dose?
0.15 mg/kg x 15 kg = 2.25 mg (round up to 2.5 mg, minimum dose).
Two culturally competent nursing actions with Latino families?
Involve extended family, show respect, use interpreter, explain isolation with empathy.
Give an example of A from SBAR in regards to Marias condition
..........
What respiratory signs signal distress in Maria?
What is Nasal flaring, retractions, wheezing, grunting, tachypnea?
How do you explain isolation to Sara?
“To keep Maria and others safe, we wear protective clothing that stops the virus from spreading.”
Why use continuous pulse oximetry?
To monitor for sudden drops in oxygen saturation indicating worsening respiratory distress.
What effects does hospitalization have on toddlers?
Separation anxiety, regression, irritability, disrupted routines.
What’s included in nasal suctioning teaching?
Teach Sara bulb/Neosucker use, positioning, signs of distress, return demonstration.
How do you calculate Maria’s maintenance fluids?
What is 100 mL/kg for first 10 kg, 50 mL/kg for next 5 kg → 15 kg = 1000 + 250 = 1250 mL/day.
What lab/diagnostic results are expected in RSV?
WBC ↑, chest x-ray → bilateral infiltrates.
When should Tylenol be given?
For fever >100.4°F; Maria gets 160 mg PO/PR q4h prn.
How would you provide family-centered care?
Involve Sara in decisions, explain treatments, address concerns, promote bonding.
What symptoms require calling the provider?
Fever >101°F, poor feeding, wheezing, retractions, grunting, or low O2 sat.
Calculate Maria’s PEWS score and interpret it.
What is HR, RR, behavior, O2 needs, etc. Maria scores 5–6 → Needs immediate provider notification.
How is RSV transmitted and how can it be prevented?
Spread via droplets and surfaces; hand hygiene, avoiding crowds, cleaning surfaces help prevent it
Marias O2 has suddenly dropped to 82% what do you do?
Administer O2, call provider, prepare for escalation (possible HFNC or transfer)
How would you respond to “I feel like the worst mother”?
“You’re doing everything you can to help Maria. You noticed she was sick and brought her in. That’s what a great mom does.”
What education to give about RSV season?
Peak in fall/winter; spread via contact/droplets; hand hygiene, limit exposure, clean toys.