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Question 1 of 57
History and Physical
The emergency department (ED) is caring for a 9-month-old male client who was brought to the ED for nasal congestion, cough, fever, and difficulty breathing. The client and his sister both attend daycare daily while their parents are at work. The sister has been acting a bit run down but has not had a fever or oxygen deficit.
Nurse’s Notes
13:30
Upon initial focused assessment, the child reveals subcostal retractions, nasal drainage, skin is hot to the touch, and has a dry cough. Breath sounds reveal diffuse wheezing. Nasal swabs collected and sent to the laboratory. Client’s weight is 12 pounds (5.4 kg).
14:00
Administered acetaminophen PO. Respiratory therapy called for oxygen therapy. 14:45
Respiratory rate and oxygen saturation improved. Temperature is within normal limits. The laboratory called with respiratory panel results. The client is positive for respiratory syncytial virus (RSV).
Laboratory Results
Laboratory
Results
Reference Ranges
Nasal culture Positive for respiratory syncytial virus Negative
Flowsheet Vital Signs
• Temperature: 103°F (39.4°C) recently
• Heart rate: 200 beats/minute
• Respirations: 70 breaths/minute
• Oxygen saturation: 90% on room air
Orders
• Administer 2.5 mL acetaminophen PO every 4 to 6 hours for temperature over 100.4°F (38°C).
• Obtain nasal swab for respiratory nasal culture.
Chart Reviewed: For each statement, click to indicate whether the statement is true or false.
The emergency department (ED) is caring for a 9-month-old male client who was brought to the ED for nasal congestion, cough, fever, and difficulty breathing. The client and his sister both attend daycare daily while their parents are at work. The sister has been acting a bit run down but has not had a fever or oxygen deficit.
Nurse’s Notes
13:30
Upon initial focused assessment, the child reveals subcostal retractions, nasal drainage, skin is hot to the touch, and has a dry cough. Breath sounds reveal diffuse wheezing. Nasal swabs collected and sent to the laboratory. Client’s weight is 12 pounds (5.4 kg).
14:00
Administered acetaminophen PO. Respiratory therapy called for oxygen therapy. 14:45
Respiratory rate and oxygen saturation improved. Temperature is within normal limits. The laboratory called with respiratory panel results. The client is positive for respiratory syncytial virus (RSV).
Laboratory Results
Laboratory
Results
Reference Ranges
Nasal culture Positive for respiratory syncytial virus Negative
Flowsheet Vital Signs
• Temperature: 103°F (39.4°C) recently
• Heart rate: 200 beats/minute
• Respirations: 70 breaths/minute
• Oxygen saturation: 90% on room air
Orders
• Administer 2.5 mL acetaminophen PO every 4 to 6 hours for temperature over 100.4°F (38°C).
• Obtain nasal swab for respiratory nasal culture.
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