8-year-old male admitted with cystic fibrosis reports:
- Shortness of breath
- Wheezing throughout lung fields
- Productive cough with thick sputum
A nurse is creating a plan of care for a newly admitted child. Which of the following actions should the nurse include in the plan?
Initiate droplet isolation precautions.
Keep the child on NPO status for 12 hr.
Maintain the child on bed rest for 24 hr.
Administer high-dose antibiotic therapy.
The Correct Answer is D
A. Initiate droplet isolation precautions is incorrect because cystic fibrosis is not transmitted by droplets, but by autosomal recessive inheritance.
B. Keep the child on NPO status for 12 hr is incorrect because there is no indication for withholding oral intake in this child. The child needs adequate hydration and nutrition to prevent dehydration and malnutrition due to increased metabolic demands and mucus production.
C. Maintain the child on bed rest for 24 hr is incorrect because bed rest can worsen the child's respiratory status by decreasing lung expansion and increasing mucus retention. The child needs to be encouraged to ambulate and participate in activities as tolerated to promote airway clearance and prevent atelectasis and infection.
D. Administer high-dose antibiotic therapy is correct because the child has signs of a pulmonary infection, such as wheezing, productive cough, and thick sputum. Antibiotics are indicated to treat the infection and prevent complications such as pneumonia and bronchiectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- Seizure precautions are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical activity in the brain that can cause changes in behavior, movement, sensation, or consciousness. Seizure precautions include providing a safe environment, monitoring the client's vital signs and neurological status, administering anticonvulsant medications, and documenting the onset, duration, and characteristics of any seizure activity.
- One of the potential complications of a seizure is aspiration, which is the inhalation of foreign material into the lungs, such as saliva, vomit, or food. Aspiration can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiration, the practical nurse (PN) should ensure the ready availability of equipment to perform suctioning of the trachea, which is the tube that connects the mouth and nose to the lungs. Suctioning of the trachea involves inserting a catheter through the nose or mouth into the trachea and applying negative pressure to remove any secretions or debris from the airway.
- Therefore, option A is the correct answer, while options B, C, and D are incorrect.
Option B is incorrect because inserting a urinary catheter is not related to seizure precautions or aspiration prevention.
Option C is incorrect because applying soft restraints may not be necessary or appropriate for a client who requires seizure precautions, as they may interfere with the natural movements of the seizure or cause injury to the client.
Option D is incorrect because inserting a nasogastric tube is not related to seizure precautions or aspiration prevention.
Correct Answer is A
Explanation
A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.
B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.
C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.
D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.
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