A nurse is assisting in the care of a child who has cystic fibrosis and a prescription for pancreatic enzymes. Which of the following outcomes is a desired effect of the pancreatic enzymes?
Passing one or two formed stools each day
Maintaining an oxygen saturation of 54% or higher
Maintaining a fasting blood glucose of less than 120 mg/dL (70 to 110 mg/dL)
Losing 0.5 kg per week
The Correct Answer is A
A. Passing one or two formed stools each day is correct. Pancreatic enzymes help improve digestion and nutrient absorption in children with cystic fibrosis. A desired outcome is a reduction in fatty, foul-smelling, bulky stools (steatorrheA. and a more normal stool consistency.
B. Maintaining an oxygen saturation of 54% or higher is incorrect. An oxygen saturation of 54% is dangerously low and not an expected outcome for cystic fibrosis management. Oxygen saturation levels should ideally be above 90%.
C. Maintaining a fasting blood glucose of less than 120 mg/dL (70 to 110 mg/dL) is incorrect. While cystic fibrosis-related diabetes can occur, pancreatic enzyme therapy does not directly regulate blood glucose levels.
D. Losing 0.5 kg per week is incorrect. Weight loss is a sign of malabsorption and poor nutritional status, indicating that pancreatic enzyme therapy may need to be adjusted. The goal is weight maintenance or gain, not loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Applying cushioning to the edge of the cast using adhesive tape is incorrect. While padding the edges of the cast can prevent skin irritation, it is not the priority in the first few hours after application. Circulatory status must be assessed first.
B. Using a fan to circulate air around the cast is incorrect. Although plaster casts generate heat as they dry and can be uncomfortable, using a fan is not a priority over assessing circulation and neurovascular function.
C. Repositioning the toddler every 2 hours is important to prevent pressure ulcers and discomfort but is not the immediate priority. Ensuring adequate circulation to the extremities takes precedence.
D. Checking the color and temperature of the toddler's toes is correct. A spica cast can impair circulation, leading to complications such as compartment syndrome. Assessing the color and temperature of the toes helps determine if blood flow is adequate. Pale, cool toes could indicate compromised circulation, requiring immediate intervention.
Correct Answer is B
Explanation
A. Hyperactive bowel sounds is incorrect. Sepsis is often associated with decreased gastrointestinal motility, leading to hypoactive or absent bowel sounds rather than hyperactivity.
B. Disorientation is correct. Mental status changes, such as confusion, irritability, or disorientation, can be an early sign of sepsis due to systemic infection and inadequate oxygenation.
C. Hypoglycemia is incorrect. Sepsis is more commonly associated with hyperglycemia due to the body's stress response. However, prolonged sepsis and organ dysfunction can eventually lead to hypoglycemia in later stages.
D. Polyuria is incorrect. In sepsis, fluid shifts and decreased organ perfusion often lead to oliguria (decreased urine output), not increased urination.
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