A nurse is caring for a child who has cystic fibrosis and receives chest physiotherapy (CPT). Which of the following actions should the nurse plan to take?
Perform vibration during the client's inspirations.
Percuss each lung segment for 15 min.
Administer albuterol prior to CPT.
Perform CPT immediately after the child eats.
The Correct Answer is C
A. Vibration is typically performed during exhalation, not inspiration. This helps to loosen secretions.
B. Percussion should not last 15 minutes per lung segment; it is generally performed for shorter periods to avoid discomfort or injury.
C. Administering albuterol prior to CPT helps open the airways, making it easier for the child to expectorate secretions. This is a standard practice for improving the effectiveness of CPT.
D. It is not recommended to perform CPT immediately after a meal, as it may increase the risk of aspiration or discomfort. It is usually advised to wait at least 30 minutes after eating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pyloric stenosis typically causes projectile vomiting shortly after feedings. After vomiting, the infant may still appear hungry and may want to feed again. This is because the blockage prevents food from entering the small intestine, causing the infant to feel hungry soon after vomiting.
B. One of the classic physical findings of pyloric stenosis is a palpable "olive-shaped" mass in the upper abdomen, which is usually located in the right upper quadrant. This mass is the enlarged pyloric muscle.
C. Jelly-like stools are more characteristic of intussusception, not pyloric stenosis.
D. While the child may show signs of discomfort or irritability due to hunger, severe pain in the abdomen is not a hallmark of pyloric stenosis.
Correct Answer is []
Explanation
Potential condition- Intussusception
Intussusception is a condition where one part of the intestine folds into another part, causing an obstruction. It is common in infants and toddlers and typically presents with the following signs- Severe abdominal pain, which causes the child to pull their knees to their chest (classic sign of colicky abdominal pain), red, jelly-like stools (which indicate the presence of blood and mucus in the stool) and palpable mass in the right upper quadrant (which could be the telescoping portion of the bowel).
Actions to Take
- Place child on NPO status:
The child should be placed on nothing by mouth (NPO) status to prepare for potential procedures, such as an enema or surgery. This prevents aspiration during any intervention and ensures the bowel is not further irritated by food or liquid intake.
- Prepare child for an air enema:
Air enema is a non-invasive treatment for intussusception. It is often used to reduce the telescoping bowel by using air under fluoroscopic guidance. This treatment can resolve the condition in many cases without the need for surgery. The nurse must ensure the child is properly prepared for this procedure (e.g., ensuring the child is NPO, monitoring vitals, and explaining the procedure to the family).
Parameters to Monitor
- Stool patterns:
Monitoring the stool patterns is essential to assess the progress and severity of intussusception. The presence of red, jelly-like stools (blood and mucus) is characteristic of intussusception, and any changes in stool appearance can help evaluate the effectiveness of treatment. The nurse should monitor if the stool pattern changes after the air enema or surgical intervention.
- Abdominal pain:
Abdominal pain is a hallmark symptom of intussusception, and the nurse should continually assess the child's pain level. The child may experience intermittent, severe cramp-like pain due to the bowel obstruction. Monitoring and managing the pain effectively is crucial for patient comfort and well-being.
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