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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Elevate the right leg above heart level. This is contraindicated for the adolescent because elevating the leg above heart level can increase blood pressure in the injured area and worsen bleeding and swelling.

B. Prepare the adolescent for surgery. This is anticipated for the adolescent because they have an open fracture with bone displacement, which requires surgical intervention to reduce the risk of infection and complications.

C. Remove the splint. This is contraindicated for the adolescent because removing the splint can cause further damage to the bone and soft tissues and increase pain and bleeding.

D. Apply ice to the affected extremity. This is contraindicated for the adolescent because applying ice can decrease blood flow to the injured area and impair healing and sensation.

A. Determine previous coping skills used by the client. B. Facilitate the client's problem-solving skillls C. Assist the client in expressing alternative behaviours. D. Establish the responsibilities of the nurse and client

Correct Answer is D

Explanation

Choice A reason:
Determine previous coping skills used by the client is not appropriate. Assessing the client's previous coping skills is an essential step in the assessment phase of the therapeutic relationship, not specifically during the orientation phase. This information helps the nurse to understand the client's coping mechanisms and identify potential areas for improvement or support.
Choice B reason:
Facilitate the client's problem-solving skills is not appropriate the nurse may work on facilitating the client's problem-solving skills throughout the therapeutic relationship, including during the working phase. During this phase, the nurse and client collaborate to explore and address the client's concerns and challenges.
Choice C reason:
Assisting the client in expressing alternative behaviours is not appropriate. This action may also be part of the working phase, where the nurse helps the client explore alternative behaviours and coping strategies to address their issues and challenges.
Choice D reason:
The orientation phase is the initial stage of the therapeutic relationship where the nurse and the client get to know each other and establish the groundwork for their working relationship. During this phase, it is essential to clarify the roles and responsibilities of both the nurse and the client to ensure a clear understanding of each other's expectations.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is building a therapeutic relationship with a newly admitted client. Which of the following actions should the nurse plan to take during the orientation phase of the relationship?

Correct Answer is D

Explanation

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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?