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 D
Explanation
A. The client is taking numerous deep, measured breaths. This is not an indication of potential violence, but rather a coping strategy to calm down and regulate emotions.
B. The client is calmly telling their partner that "the staff here is so controlling." This is not an indication of potential violence, but rather a expression of frustration or dissatisfaction with the treatment setting.
C. The client is sitting with their head in their hands and appears to be crying. This is not an indication of potential violence, but rather a sign of sadness or distress.
D. The client is pacing around the chair in which their partner is sitting. This is an indication of potential violence, as it shows restlessness, agitation, and possible intimidation of the partner.
Correct Answer is B
Explanation
Choice A reason
While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.
Choice B reason.
Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure.
Choice C reason:
While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.
Choice D reason:
Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.
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