8-year-old male admitted with cystic fibrosis reports:
- Shortness of breath
- Wheezing throughout lung fields
- Productive cough with thick sputum
A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?
Initiate droplet isolation precautions.
Keep the child on NPO status for 12 hr.
Maintain the child on bed rest for 24 hr.
Administer high-dose antibiotic therapy.
The Correct Answer is D
A. Initiate droplet isolation precautions is incorrect because cystic fibrosis is not transmitted by droplets, but by autosomal recessive inheritance.
B. Keep the child on NPO status for 12 hr is incorrect because there is no indication for withholding oral intake in this child. The child needs adequate hydration and nutrition to prevent dehydration and malnutrition due to increased metabolic demands and mucus production.
C. Maintain the child on bed rest for 24 hr is incorrect because bed rest can worsen the child's respiratory status by decreasing lung expansion and increasing mucus retention. The child needs to be encouraged to ambulate and participate in activities as tolerated to promote airway clearance and prevent atelectasis and infection.
D. Administer high-dose antibiotic therapy is correct because the child has signs of a pulmonary infection, such as wheezing, productive cough, and thick sputum. Antibiotics are indicated to treat the infection and prevent complications such as pneumonia and bronchiectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Incorrect. The client does not have respiratory alkalosis because respiratory alkalosis is characterized by a low PaCO2 (less than 35 mm Hg) and a high pH (greater than 7.45).
B. Incorrect. The client does not have metabolic alkalosis because metabolic alkalosis is characterized by a high HCO3 (greater than 26 mEq/L) and a high pH (greater than 7.45).
C. Correct. The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).
D. Incorrect. The client does not have metabolic acidosis because metabolic acidosis is characterized by a low HCO3 (less than 22 mEq/L) and a low pH (less than 7.35).
Correct Answer is D
Explanation
Choice A reason:
Increased urinary frequency Increased urinary frequency is not a typical adverse effect of sertraline. However, some individuals may experience changes in urinary habits due to various factors, but it is not directly related to sertraline use.
Choice B reason
Dry cough Dry cough is not a commonly reported adverse effect of sertraline. Cough is not a typical symptom associated with this medication.
Choice C reason
Metallic taste in the mouth While some individuals may experience changes in taste as a side effect of sertraline, a metallic taste in the mouth is not one of the commonly reported adverse effects. Taste changes are usually mild and temporary.
Choice D reason
Sertraline is a selective serotonin reuptake inhibitor (SSRI) antidepressant commonly used to treat conditions like depression, anxiety disorders, and obsessive-compulsive disorder. While most individuals tolerate sertraline well, it can cause certain adverse effects, and excessive sweating (also known as diaphoresis) is one of them.
Excessive sweating is a common side effect of sertraline and other SSRIs. It can manifest as increased sweating during the day or night, even in cooler environments. The degree of sweating can vary among individuals, and some may experience it more than others.
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