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 A
Explanation
A. This choice is correct because a child who has autism spectrum disorder often exhibits strict adherence to routines and rituals, and may become distressed or agitated when there are changes or disruptions to their usual patterns.
B. This choice is incorrect because difficulty paying attention to tasks is not a specific manifestation of autism spectrum disorder, but rather a common symptom of attention-deficit/hyperactivity disorder (ADHD). A child who has autism spectrum disorder may have difficulty focusing on tasks that are not of interest to them, but may also show intense concentration on tasks that are of interest to them.
C. This choice is incorrect because disobedience to authority figures is not a specific manifestation of autism spectrum disorder, but rather a common behavior problem in children and adolescents. A child who has autism spectrum disorder may have difficulty understanding social cues and expectations, but may also show compliance and cooperation when given clear instructions and positive reinforcement.
D. This choice is incorrect because excessive anxiety when separated from parents is not a specific manifestation of autism spectrum disorder, but rather a common symptom of separation anxiety disorder. A child who has autism spectrum disorder may have difficulty forming attachments and expressing emotions, but may also show affection and attachment to familiar people.
Correct Answer is A
Explanation
A is correct because it is a direct and respectful way of addressing the issue with the nurse who is violating the unit policies. It also opens up a dialogue for possible solutions and feedback.
B is incorrect because it is a threatening and punitive statement that does not address the root cause of the problem or offer any constructive feedback.
C is incorrect because it is a passive-aggressive and guilt-inducing statement that does not clearly communicate the expectations or consequences of violating the unit policies.
D is incorrect because it is an irrelevant and deflecting statement that does not address the issue of taking an extended amount of time for break.
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