A nurse is caring for a child who has cystic fibrosis and is taking dornase alfa. Which of the following actions should the nurse take to evaluate the effectiveness of the medication?
Determine the child's heart rate.
Weigh the child daily.
Auscultate the child's breath sounds.
Monitor the child's 180.
The Correct Answer is C
Choice A reason:
Determining the child's heart rate is important for assessing overall cardiovascular health, but it is not specific to evaluating the effectiveness of dornase alfa.
Choice B reason:
Weighing the child daily is important for monitoring overall nutritional status and fluid balance, but it is not specific to evaluating the effectiveness of dornase alfa.
Choice C reason:
Dornase alfa is a medication used to help clear mucus from the airways in individuals with cystic fibrosis. Therefore, auscultating the child's breath sounds for improved air exchange and reduced adventitious lung sounds is a direct way to evaluate the effectiveness of the medication.
Choice D reason:
Monitoring the child's 180 (assuming this is a typo and referring to heart rate) is important, but it is not specific to evaluating the effectiveness of dornase alfa.
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Related Questions
Correct Answer is D
Explanation
A: Introducing fruit juice at 4 months old is not recommended because infants' digestive systems are not yet ready for such foods, and it can increase the risk of tooth decay and obesity.
B: Introducing eggs at 6 months could be appropriate; however, it is not the best choice as it does not reflect the gradual introduction of new foods one at a time, which is essential to monitor for any allergic reactions or food intolerances.
C: Offering cereal with a percent of milk is not advisable for a 4-month-old infant as cow's milk should not be introduced until the child is at least 12 months old due to the risk of iron deficiency and potential allergies.
D: Offering a new food every 7 days is the correct approach as it allows parents to introduce new foods gradually and monitor the infant for any adverse reactions or allergies, which aligns with the guidelines provided by health authorities.
Correct Answer is A
Explanation
Choice A reason:
Diminished pulses can be indicative of decreased cardiac output, as it suggests that there may be a reduction in the volume of blood being pumped by the heart.
Choice B reason:
Extremities warm to touch is not necessarily indicative of decreased cardiac output. It may be related to other factors, such as ambient temperature or local blood flow.
Choice C reason:
Capillary refill of 2 seconds is within the normal range for a preschooler, and it is not a strong indicator of decreased cardiac output.
Choice D reason:
A blood pressure of 112/66 mm Hg is within the normal range for a preschooler and is not a strong indicator of decreased cardiac output.
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