RSV & Respiratory Care
Name three assessment findings that indicate increased work of breathing in an infant with RSV.
Accept any three: retractions, nasal flaring, grunting, head bobbing or tachypnea.
Rationale: Assess respiratory effort together with oxygen saturation, breath sounds, feeding and alertness. Apnea or decreasing responsiveness requires emergency escalation.
Why does a vaso-occlusive sickle cell crisis cause severe limb pain?
Rigid sickled red blood cells obstruct small vessels, reducing blood flow and tissue oxygen delivery.
Rationale: Ischemia causes pain. The nurse should believe the patient report and assess and treat pain promptly.
A child returns from appendectomy and is still drowsy from anesthesia. What should the nurse assess first?
Airway patency and adequacy of breathing/oxygenation, followed promptly by circulation and level of consciousness.
Rationale: Postanesthesia airway obstruction or hypoventilation takes priority over the incision, diet or routine teaching.
A surgical drain contains thin, watery pink fluid. What is this drainage called, and what should the nurse document?
Serosanguineous drainage. Document amount, color/character, time interval, insertion-site condition and drain function.
Rationale: Interpret the trend with the procedure and patient assessment; the color alone does not establish that recovery is normal.
Breastfeeding: A parent reports nipple pinching and the newborn repeatedly slips off the breast. What should the nurse assess first, and name one sign of an effective latch?
Observe positioning and latch directly. Accept a wide-open mouth with a deep latch, flanged lips, rhythmic suck/swallow or comfortable feeding with effective milk transfer.
Rationale: A shallow latch can cause pain and poor transfer. Time at breast alone does not prove adequate intake.
A 3-month-old with RSV is alert but cannot feed well because of copious nasal secretions. What supportive intervention should the nurse perform, and what should be reassessed?
Perform gentle nasal suctioning according to policy when secretions interfere with breathing or feeding, especially before a feed. Reassess work of breathing, oxygenation and feeding tolerance.
Rationale: Infants rely heavily on nasal breathing. Avoid aggressive, unnecessary deep suctioning.
A 6-year-old with sickle cell disease reports severe leg pain but is watching a video. Which pain assessment approach is most appropriate?
Use an age-appropriate self-report tool, such as a FACES scale if understood, and ask about location, intensity, quality and previous helpful treatments.
Rationale: Distraction or quiet behavior does not exclude severe pain. Parent observations supplement the child self-report.
Before surgery, a child with suspected appendicitis reports sudden pain relief, then develops diffuse abdominal pain and rigidity. What should the nurse suspect and do?
Suspect perforation with peritoneal irritation. Notify the surgical team urgently, assess vital signs/perfusion, maintain NPO status and prepare prescribed treatment.
Rationale: Temporary pain relief followed by worsening diffuse symptoms is not reassuring. Avoid laxatives or enemas.
After emptying a Jackson-Pratt drain, a student replaces the cap while the bulb is fully expanded. What needs correction and why?
Compress the bulb and close the cap while compressed, following device instructions. Confirm that suction is maintained and record the measured output.
Rationale: A compressed, sealed bulb provides gentle negative pressure; a fully expanded bulb will not provide the intended suction.
Central line care: A transparent dressing is damp and lifting at the edges before its scheduled change. What should the nurse do, and name two infection-prevention steps?
Replace it promptly using the required aseptic technique. Perform hand hygiene and use the appropriate sterile supplies/PPE; clean with the approved antiseptic and allow it to dry fully.
Rationale: A damp or loose dressing no longer protects the site. Stabilize the catheter and assess the site; do not wait for the routine change date.
An infant with RSV takes less than half the usual feeds and has only one wet diaper in 12 hours. Name the main concern and two focused assessments.
Concern: dehydration. Assess perfusion (capillary refill, pulses, heart rate) and hydration (mucous membranes, fontanel, weight and urine output). Notify the provider and plan safe fluid support.
Rationale: Poor intake and reduced urine output need prompt assessment. Significant respiratory distress may make oral feeding unsafe.
A child in pain crisis has dry lips, poor intake, normal breathing and SpO2 97% on room air. Name three appropriate parts of the initial care plan.
Prompt prescribed analgesia with reassessment; assess hydration and give individualized oral/IV fluids as ordered; use comfort measures such as warmth and distraction. Monitor sedation, breathing and fluid balance.
Rationale: Treat pain and dehydration without overhydration. Oxygen is indicated for hypoxemia or another clinical indication, not automatically for every crisis.
A 6-year-old is receiving IV piperacillin-tazobactam after removal of a ruptured appendix. Name three safety checks before giving the dose.
Verify allergies, especially beta-lactam reactions; verify the dose using current weight in kilograms, ordered dosing basis and renal function; check IV patency, dilution, compatibility and infusion rate.
Rationale: Antibiotics treat contamination/infection after rupture, but pediatric administration requires dose and IV safety checks. Clarify discrepancies before administration.
A surgical drain that was producing fluid suddenly has no output. The patient reports increasing swelling and discomfort near the incision. What should the nurse do?
Assess the patient, insertion site, tubing for kinks and connections, and prescribed suction. Correct simple external kinks, then notify the surgical team promptly if obstruction or loss of function is suspected.
Rationale: No output with swelling may mean retained fluid, not resolution. Do not strip, irrigate or remove the drain without an order/protocol.
Blood administration: Ten minutes into packed RBCs, a patient develops chills, back pain and dyspnea. What is the FIRST action and what follows?
Stop the transfusion immediately. Assess ABCs and vital signs, activate urgent help as needed, and notify the provider and blood bank. Maintain IV access with new tubing and normal saline per policy; recheck identification and retain the bag/tubing for investigation.
Rationale: Suspect a transfusion reaction. Do not flush remaining blood into the patient or restart this unit.
A 3-month-old with RSV has persistent SpO2 88% on room air and retractions after gentle suctioning. A teammate suggests waiting for routine albuterol. What is the priority?
Provide oxygen per protocol, reassess airway/breathing and summon the provider/respiratory team for escalation.
Rationale: Persistent hypoxemia requires support now. Routine albuterol is not recommended for uncomplicated bronchiolitis and must not delay oxygenation or escalation.
A child hospitalized for sickle cell pain develops fever, chest pain, cough and SpO2 88%. What serious complication is suspected, and what should the nurse do?
Suspect acute chest syndrome. Initiate urgent respiratory assessment, oxygen and emergency escalation; prepare for ordered testing and treatment.
Rationale: Acute chest syndrome is life-threatening. Do not assume the chest pain is only part of the usual pain crisis.
During an IV antibiotic infusion after appendectomy, the child reports burning. The IV site is swollen and cool, and the pump alarms. What should the nurse do first and next?
Stop the infusion immediately. Assess the site and distal circulation, do not flush, and follow the infiltration/extravasation protocol for the medication. Notify the appropriate clinician and establish safe access for ongoing therapy.
Rationale: Cool swelling suggests infiltration. Determine whether aspiration or an antidote is required before removing the catheter.
Drainage changes from a small pink amount to a rapid increase in bright-red blood. HR rises and BP falls. Which action takes priority over measuring the next hourly output?
Activate urgent response and notify the surgical team while assessing/supporting ABCs and perfusion. Maintain IV access and prepare prescribed resuscitation; quantify output without delaying care.
Rationale: Increasing bloody drainage plus instability suggests active hemorrhage. Do not routinely clamp the drain to stop bleeding.
Chest tube: A patient suddenly becomes dyspneic with SpO2 86%. The drainage tubing is kinked under the patient. What should the nurse do immediately, and what action should be avoided?
Relieve the external kink promptly while assessing the patient, supporting oxygenation and calling for urgent help. Keep the drainage system upright below chest level and reassess breathing and system function.
Rationale: Obstruction can prevent air/fluid drainage and cause deterioration. Do not routinely clamp or strip the chest tube; follow emergency protocol and orders.
An infant with RSV was breathing rapidly but is now breathing more slowly, has less chest movement, is difficult to arouse and has pauses in breathing despite oxygen. Improvement or deterioration? What comes first?
Deterioration with respiratory fatigue and impending failure. Activate emergency response and immediately support airway and ventilation, including bag-mask ventilation if breathing is inadequate, per pediatric resuscitation protocol.
Rationale: Less effort with lethargy/apnea is not recovery. Do not delay for feeding, medications or routine documentation.
During sickle cell treatment, a child suddenly develops facial droop, right arm weakness and slurred speech. What is the priority response?
Activate the emergency/stroke response immediately, note last-known-well time and support ABCs. Check glucose promptly per protocol without delaying the stroke response; keep the child NPO pending swallowing assessment.
Rationale: Focal neurologic deficits may indicate stroke. Urgent specialist evaluation and transfusion planning may be needed; pain reassessment can wait.
On day 2 after surgery for a ruptured appendix, a child has fever 39 C, HR 150, capillary refill 4 seconds, worsening rigid abdomen and lethargy. State the priority concern and actions.
Possible intra-abdominal infection with sepsis and poor perfusion. Activate urgent response and notify the surgical team; assess/support ABCs and initiate the pediatric sepsis pathway, including ordered IV fluids, antibiotics and investigations.
Rationale: Multisystem deterioration is an emergency. Do not wait for hypotension or treat fever alone.
A postoperative child becomes difficult to arouse after IV morphine, with RR 6/min and shallow breathing. What are the immediate nursing actions?
Stop further opioid administration, call emergency assistance and support airway/ventilation immediately. Give oxygen and assisted ventilation as indicated; prepare/administer prescribed naloxone per protocol. Reassess continuously for recurrent sedation.
Rationale: Ventilatory support cannot wait for reversal medication. Oxygen saturation alone does not measure adequate ventilation.
EKG priority: An adult monitor shows a rapid, regular wide-complex rhythm. The patient is unresponsive, has no normal breathing and no definite pulse within 10 seconds. What rhythm emergency and actions should the nurse identify?
Treat as pulseless ventricular tachycardia, a shockable cardiac arrest. Activate the code response, begin high-quality CPR and use the defibrillator/AED as soon as available, following the adult resuscitation algorithm.
Rationale: Confirm patient status, not just the monitor. Pulseless VT requires defibrillation; synchronized cardioversion is used for selected unstable rhythms WITH a pulse.