The practical nurse (PN) is assisting with the admission of a 12-month-old child with a history of frequent colds and growth failure. Testing is being planned for a possible diagnosis of cystic fibrosis (CF). Which information is most important for the PN to obtain?
The number of respiratory infections since birth.
The number of siblings in the family.
A description of the child's appetite.
The pattern of bowel movements.
The Correct Answer is D
The pattern of bowel movements is the most important information for the practical nurse (PN) to obtain when assisting with the admission of a 12-month-old child with a history of frequent colds and growth failure who is being tested for a possible diagnosis of cystic fibrosis (CF). CF can cause thick, sticky mucus to build up in the digestive tract, leading to problems with digestion and absorption of nutrients. This can result in bulky, greasy stools and growth failure.
The number of respiratory infections since birth (Option A) and a description of the child's appetite (Option C) are also important pieces of information, but they are not as critical as the pattern of bowel movements. The number of siblings in the family ( Option B) is not directly relevant to the child's medical condition.
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Correct Answer is D
Explanation
The newborn assessment finding that the practical nurse (PN) should report to the charge nurse immediately for a 24-hour-old infant is a heart rate of 100 beats/minute. The normal heart rate for a newborn is between 120-160 beats/minute. A heart rate of 100 beats/minute is below the normal range and may indicate a problem such as hypothermia or an infection. The PN should report this finding to the charge nurse immediately so that appropriate action can be taken to address the issue. The other assessment findings listed may also be important to monitor, but a heart rate of 100 beats/minute is the most urgent and requires immediate attention.
Correct Answer is C
Explanation
For a child with heart failure, the greatest priority for the practical nurse (PN) is to conserve the child's energy. Clustered care activities and rest periods will help to conserve the child's energy and minimize the workload on the heart.
Monitoring therapeutic levels of phenytoin (A) is not relevant to the care of a child with heart failure. Increasing fluid intake (B) is not a priority intervention for a child with heart failure, as excessive fluid intake can worsen heart failure. Restricting intake of foods high in sugar (D) may be necessary for a child with heart failure, but it is not the greatest priority for the PN to address.
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