Need an NCLEX question r/t RSV

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Specializes in Psych, LTC, Home Health.

Anyone got any ideas?

Thanks in advance!

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Here is a question from page 429 of Saunders Comprehensive Review for the NCLEX-RN Examination, 3rd edition, by Linda Anne Silvestri:

Ribavirin (Virazole) is prescribed for a hospitalized child with respiratory syncytial virus. The nurse prepares to administer this medication via which of the following routes?

  1. Subcutaneous
  2. Intramuscular
  3. Oxygen tent
  4. Oral

Answer and strategy (page 431): 3

Rationale: Ribavirin (Virazole) is an antiviral respiratory medication used mainly in hospitalized children with severe RSV. Administration is via hood, face mask, or oxygen tent. Ribavirin is not administered subcutaneously, intramuscularly, or orally.

Test-Taking Strategy: Use the process of eliminating. Recalling that this medication is aerosolized will direct you to option #3. If you are unfamiliar with this medication, review its method of administration.

Level of Cognitive Ability: Application

Client Needs: Physiological Integrity

Integrated Processs: Nursiing Process--planning

Reference: Wong, D., Hockenberry-Eaton, M. (2000). Wong's Essentials of Pediatric Nursing (6th ed. p. 842). St. Louis: Mosby.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

Here's another question from the same page. I'm not paying attention to what I'm doing here (I'm multi-tasking):

A nurse is caring for an infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus. Based on this finding, which of the following would be the most appropriate nursing action?

  1. Move the infant to a room with another child with RSV.
  2. Leave the infant in the present room because RSV is not contagious.
  3. Inform the staff that they must wear a mask when caring for the child.
  4. Initiate strict enteric precautions.

Answer (page 431): 1

Rationale: Respiratory syncytial virus is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands, and meticulous hand washing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary; however, the nurse should wear a gown when soiling of clothing may occur.

Test-taking strategy: Use the process of elimination. Recall the method of the transmission and that the infant with RSV is isolated in a single room or placed in a room with another child with RSV. Review the care of the infant with RSV if you had difficulty with this question.

Reference: Wong, D., Hockenberry-Eaton, M. (2000). Wong's Essentials of Pediatric Nursing (6th ed. p. 842). St. Louis: Mosby.

Some information from page 423 of the book you might want to know about RSV:

Interventions:

  • Maintain a patent airway
  • Position the child at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm.
  • Provide cool, humidified oxygen.
  • Encourage fluids; fluid administered intravenously may be necessary until the acute stage has passed.
  • Assess for signs of dehydration

Also,

  • Isolate the child in a single room or place in a room with another child with RSV.
  • Maintain good hand-washing procedures.
  • Ensure that nurses caring for these children do not care for other high-risk children.
  • Wear gowns when soiling of clothing may occur during care.
  • Administer ribavirin (Virazole), an antiviral respiratory medication, if prescribed. (Administer ribavirin via aerosol by hood, tent, mask, or through ventilator tubing. A nurse wearing contact lenses should wear goggles when coming in contact with ribavirin because the mist may dissolve soft lenses. Pregnant health care providers should not care for a child receiving ribavirin.)
  • Prepare for the administration of respiratory syncytial virus immune globulin (RSV-IGIV or RespiGam or palivizumab[sunagis]). (The immune globulin is used prophylactically to prevent respiratory syncytial virus infection in high-risk infants. The immune globulin is not administered to infants or children with congenital heart disease or with cyanotic congenital heart disease.)

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Specializes in Psych, LTC, Home Health.

That is perfect! Thanks so much! :D

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Thanks for taking out the time to share this. It was quite helpful.

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