A nurse is evaluating a 6-year-old child who has cystic fibrosis and has been receiving chest physiotherapy treatment.
The nurse should identify which of the following findings as an indication of the therapy has been effective?
Increased urine output
increase expectoration
reduced pain
increased heart rate .
The Correct Answer is B
Choice A rationale
Increased urine output is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Choice B rationale
Increased expectoration, or coughing up and spitting out mucus, is a sign that chest physiotherapy is effective. The goal of chest physiotherapy is to help clear the thick, sticky mucus from the lungs of children with cystic fibrosis.
Reduced pain is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Choice D rationale
An increased heart rate is not a typical indication of effective chest physiotherapy treatment in a child with cystic fibrosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Increased restlessness in a toddler with a full-thickness burn may indicate hypoxia, pain, or shock. These conditions require immediate medical attention to prevent further complications and ensure proper management of the burn injury.
Choice B rationale: A respiratory rate of 25/min is within the normal range for toddlers (20-30 breaths per minute). This finding does not indicate an immediate concern that requires reporting to the provider.
Choice C rationale: Bowel sounds of 20/min are within the normal range (5-30 sounds per minute). This finding does not indicate any gastrointestinal complications that need to be reported to the provider.
Choice D rationale: Urinary output of 35 mL/hr is within the normal range for toddlers (1-2 mL/kg/hr). This finding indicates adequate kidney function and hydration status, so it does not require immediate reporting.
Correct Answer is B
Explanation
The correct answer is choiceB.
Choice A rationale:
Dark brown blood in emesis is typically old blood and may not require immediate intervention.However, it should still be monitored and reported to the healthcare provider.
Choice B rationale:
Frequent swallowing can indicate active bleeding from the surgical site, which requires immediate intervention.This is a sign that the child may be swallowing blood, which can lead to significant blood loss.
Choice C rationale:
An axillary temperature of 38°C (100°F) is a mild fever and not uncommon postoperatively.It should be monitored, but it does not require immediate intervention.
Choice D rationale:
A pain level of 5 on the FACES scale indicates moderate pain, which is expected after a tonsillectomy.Pain management should be addressed, but it does not require immediate intervention.
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