Which finding(s) should the nurse expect to assess in a 16-year-old client diagnosed with cystic fibrosis admitted to the hospital for decreased results on pulmonary function tests (PFTs)?
Meconium ileus.
Blood-streaked sputum.
Clear breath sounds bilaterally.
Dyspnea.
The Correct Answer is B
Choice A rationale:
Meconium ileus is a concern in newborns with cystic fibrosis due to thick meconium, which can cause intestinal obstruction. At 16 years old, this complication is not relevant to the client's current condition.
Choice B rationale:
Blood-streaked sputum is a likely finding in a 16-year-old with cystic fibrosis and decreased pulmonary function. Cystic fibrosis leads to mucus accumulation and lung infections, which can cause blood vessels to rupture, resulting in blood-streaked sputum.
Choice C rationale:
Clear breath sounds bilaterally indicate healthy lung function, which is not expected in a client with cystic fibrosis and decreased PFT results. Breath sounds are likely to be diminished due to mucus accumulation.
Choice D rationale:
Dyspnea, or difficulty breathing, is a common symptom in clients with cystic fibrosis and decreased pulmonary function. However, the question asks about the expected findings that the nurse should assess, not a symptom that the client might report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
Monitoring the cardiac catheterization site for bleeding is the priority nursing intervention when a child feels nauseous and vomits after a cardiac catheterization. Bleeding from the catheterization site could lead to serious complications and requires immediate attention.
Choice A rationale:
Applying a cool cloth to the child's forehead can provide comfort, but it doesn't address the potential complication of bleeding from the catheterization site.
Choice B rationale:
Offering the child sips of orange juice is not appropriate if the child is nauseous and vomiting. Fluid intake should be monitored, but bleeding assessment takes priority.
Choice C rationale:
Applying pressure to the cardiac catheterization site is not the priority intervention. Monitoring for bleeding and assessing the site are more important.
Correct Answer is B
Explanation
Choice A rationale:
Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.
Choice B rationale:
Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.
Choice C rationale:
Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.
Choice D rationale:
Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.
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