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. Hypotension is not an adverse effect of epinephrine, but rather a sign of anaphylaxis that epinephrine can help to reverse by causing vasoconstriction and increasing blood pressure.
B. Report of tinnitus is not an adverse effect of epinephrine, but rather a symptom of aspirin toxicity, which can occur in some clients who take aspirin for allergic reactions.
C. Report of chest pain is an adverse effect of epinephrine, as it can cause cardiac dysrhythmias, angina, and myocardial ischemia by increasing the heart rate and oxygen demand of the myocardium.
D. Ecchymosis is not an adverse effect of epinephrine, but rather a sign of bleeding disorders or trauma that can cause bruising under the skin.
Correct Answer is A
Explanation
A. Correct. Avoiding exposure to tobacco smoke is one of the measures to prevent SIDS, as it can affect the respiratory function and arousal of the newborn.
B. Incorrect. Placing bumper pads in the baby's crib is not recommended, as they can pose a suffocation or strangulation hazard for the newborn.
C. Incorrect. Placing the baby's head on a pillow for sleeping is not advised, as it can increase the risk of suffocation or rebreathing of carbon dioxide for the newborn.
D. Incorrect. Placing the baby in a side-lying position for sleeping is not suggested, as it can increase the likelihood of rolling over to a prone position, which is associated with a higher incidence of SIDS.
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