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 D

Explanation

Option A is incorrect because enrolling the UAP in a hospital education class on conducting safe client care does not address the immediate problem or correct the error.

Option B-This would be inappropriate for oral care in an unconscious client as it increases the risk of aspiration.The side-lying position is safer for oral hygiene in unconscious clients.

Option C:While encouraging family participation can be beneficial, it is not the most immediate concern in this situation. The priority is ensuring safe and effective care, which the UAP is providing correctly.

Option D:The flat side-lying position is appropriate for an unconscious client during oral hygiene care. This position helps to prevent aspiration by allowing any secretions or fluids to drain out of the mouth rather than down the throat, which could happen if the client were in a Fowler's position. The presence of the emesis basin near the chin also indicates that the UAP is prepared to catch any fluids, further reducing the risk of aspiration

A. Assess the apical pulse while the newborn is crying. B. Palpate the radial pulse for 30 seconds. C. Listen to the apical pulse while palpating the radial pulse. D. Auscultate the apical pulse at least 1 min.

Correct Answer is D

Explanation

A is incorrect because assessing the apical pulse while the newborn is crying can result in an inaccurate measurement due to increased heart rate and respiratory rate.

B is incorrect because palpating the radial pulse for 30 seconds is not appropriate for a newborn as it can be difficult to locate and count accurately.

C is incorrect because listening to the apical pulse while palpating the radial pulse is not necessary for a newborn and can be confusing and time-consuming.

D is correct because auscultating the apical pulse at least 1 min is the best way to assess a newborn's heart rate as it provides an accurate and reliable measurement.

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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

The practical nurse (PN) observes an unlicensed assistive personnel (UAP) performing oral hygiene on an unconscious client who is lying in a ﬂat side-lying position with an emesis basin on the bedside table near the chin. Which action should the PN take?

Correct Answer is D

Explanation

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is assessing a client who has COPD. Which of the following findings should the nurse expect?

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?