A nurse is assisting in the care of a child in the pediatrician's office.
bone marrow failure
hypernatremia
malabsorption
chronic respiratory infections
excessive weight gain
Correct Answer : C,D
Rationale:
• Chronic respiratory infections: A positive sweat chloride test confirms cystic fibrosis, a condition characterized by thick mucus that obstructs airways, leading to persistent cough, wheezing, and a high risk of recurrent lung infections due to impaired mucus clearance.
• Malabsorption: Cystic fibrosis affects the pancreas by blocking enzyme flow needed for digestion. This results in poor nutrient absorption, causing symptoms like excessive hunger, weight loss despite eating well, and abdominal distension, all of which are evident in this child.
• Bone marrow failure: There are no signs of pancytopenia, anemia, or infection susceptibility that would suggest bone marrow dysfunction. Cystic fibrosis does not typically impact hematopoietic function directly.
• Hypernatremia: Although cystic fibrosis can lead to salt imbalances due to abnormal chloride transport, hypernatremia is not commonly a presenting concern unless there's severe dehydration, which is not evident here.
• Excessive weight gain: The child is losing weight despite increased appetite. Malabsorption from pancreatic insufficiency prevents weight gain in cystic fibrosis, making excessive weight gain an unlikely risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. “I will wait 15 minutes before taking a second tablet.": Waiting 15 minutes delays relief and increases the risk of complications. The client should take a second tablet if chest pain is unrelieved after 5 minutes, up to three doses within 15 minutes, then seek emergency help if symptoms persist.
B. "I should stop taking the medication if I get a headache.": Stopping the medication due to a headache overlooks the therapeutic benefit. Headaches are a common side effect caused by vasodilation and can be managed with mild analgesics while continuing the medication as prescribed.
C. "I should expect pain relief in 1 to 3 minutes.": Sublingual nitroglycerin is rapidly absorbed through the oral mucosa, leading to relief typically within 1 to 3 minutes. This fast onset is essential for treating acute angina episodes effectively.
D. "I will swallow the tablet for faster absorption.": Swallowing the tablet bypasses the sublingual route, delaying its effect due to first-pass metabolism in the liver. The tablet must be placed under the tongue to ensure rapid absorption and therapeutic effectiveness.
Correct Answer is C
Explanation
Rationale:
A. Don sterile gloves prior to the procedure: Clean gloves, not sterile gloves, are required for a capillary blood glucose test since it is a clean, not sterile, procedure. Sterile technique is unnecessary and not cost-effective for this type of routine testing.
B. Hold the finger in an upright position prior to the procedure: The finger should be held in a dependent (downward) position to promote blood flow to the puncture site. Holding it upright may reduce perfusion and make obtaining an adequate sample more difficult.
C. Use the lateral tip of the finger to obtain specimen: The lateral sides of the fingertip have fewer nerve endings than the center and are more vascular, making them ideal for obtaining an adequate blood sample with minimal discomfort to the client.
D. Discard the lancet in the trash container: Lancets are sharp instruments and must be discarded in an approved sharps container to prevent needle-stick injuries and ensure proper infection control. Disposing of them in regular trash poses a safety hazard.
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