심화 해설
Core Nursing Explanation
Key Concept Analysis: This question assesses the nurse's ability to prioritize care for an infant with Bronchiolitis, a common lower respiratory tract infection in infants, most often caused by Respiratory Syncytial Virus (RSV). The priority is determined by the ABCs (Airway, Breathing, Circulation) framework and the principle of treating the most immediate threat to physiological stability. While all options are relevant to care, the infant's fever of 101.8°F (38.8°C) presents a specific, acute risk.
Answer Rationale: Key Point! In infants and young children, a fever of this magnitude is a priority because it significantly increases the risk of Febrile seizures. High fever also increases metabolic rate and oxygen demand, which can worsen respiratory distress in a child whose breathing is already compromised by wheezing and congestion. Therefore, the immediate nursing intervention is to administer an antipyretic like Acetaminophen (Tylenol) to reduce the fever, prevent complications, and improve the child's overall comfort and ability to rest and breathe effectively. This action supports the "Circulation" component (preventing complications from hyperthermia) and indirectly supports "Breathing" by reducing metabolic stress.
Distractor Analysis:
Watch out for confusion! Option ②, "Position the child with the affected side down to promote drainage," is incorrect. This positioning is sometimes used for Lobar pneumonia with consolidation to improve ventilation-perfusion matching. For Bronchiolitis, which causes diffuse inflammation and mucus plugging in the Bronchioles, this position is not indicated and could impair breathing. The preferred position is semi-Fowler's or upright to maximize lung expansion.
Option ③, "Encourage increased fluid intake to thin secretions," is an important supportive measure but is not the immediate priority. Adequate hydration helps prevent thick, tenacious secretions. However, managing the acute risk of febrile seizures from the documented fever takes precedence.
Option ④, "Provide chest physiotherapy every 2 hours," is contraindicated in the acute phase of bronchiolitis. Routine chest physiotherapy (CPT) or postural drainage is not recommended for infants with bronchiolitis as it may cause irritation, worsen bronchospasm, and is not proven effective. It can also be very tiring for a distressed infant.
Related Concepts: The nursing process requires constant re-prioritization. After addressing the fever (a circulation/comfort issue), the nurse's focus would shift to respiratory status: monitoring Oxygen saturation (SpO2), respiratory rate, work of breathing (nasal flaring, retractions), and administering supplemental oxygen or nebulized medications (e.g., bronchodilators, hypertonic saline) as prescribed. Strict Infection control, including contact and droplet precautions for RSV, is also essential.
임상 시나리오
Nursing Clinical Practice Guide
Clinical Scenario: You are the nurse admitting Leo, a 6-month-old with bronchiolitis. He is fussy, tachypneic with audible wheezes, has copious nasal secretions, and feels warm to the touch. His mother is anxious.
Nursing Intervention Strategy:
1. Immediate Assessment & Priority Action: Confirm temperature, administer prescribed antipyretic (Acetaminophen 10-15 mg/kg/dose), and document. Explain to parents the purpose is safety (seizure prevention) and comfort.
2. Respiratory Management: Place infant in a semi-Fowler's position. Perform gentle nasal suctioning with a bulb syringe before feeds and as needed to clear airways. Monitor SpO2 continuously. Administer supplemental oxygen via nasal cannula or hood if SpO2 falls below 92%. Prepare for possible nebulized medication administration (e.g., albuterol trial, hypertonic saline).
3. Hydration & Nutrition: Offer small, frequent feeds (breast milk or formula). Monitor for signs of dehydration: decreased wet diapers (
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