A nurse is caring for a child who has cystic fibrosis and is taking dornase alfa. Which of the following actions should the nurse take to evaluate the effectiveness of the medication?
Determine the child's heart rate.
Weigh the child daily.
Auscultate the child's breath sounds.
Monitor the child's 180.
The Correct Answer is C
Choice A reason:
Determining the child's heart rate is important for assessing overall cardiovascular health, but it is not specific to evaluating the effectiveness of dornase alfa.
Choice B reason:
Weighing the child daily is important for monitoring overall nutritional status and fluid balance, but it is not specific to evaluating the effectiveness of dornase alfa.
Choice C reason:
Dornase alfa is a medication used to help clear mucus from the airways in individuals with cystic fibrosis. Therefore, auscultating the child's breath sounds for improved air exchange and reduced adventitious lung sounds is a direct way to evaluate the effectiveness of the medication.
Choice D reason:
Monitoring the child's 180 (assuming this is a typo and referring to heart rate) is important, but it is not specific to evaluating the effectiveness of dornase alfa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
Correct Answer is D
Explanation
Choice A reason:
Taping the wire to the palm of the hand can be uncomfortable for the child and may interfere with blood flow.
Choice B reason:
Warming the skin prior to probe placement is not a standard practice for pulse oximetry monitoring.
Choice C reason:
Applying the sensor to the index fingernail is not a recommended site for pulse oximetry monitoring in children.
Choice D reason:
Repositioning the probe every 2 hours helps to prevent skin breakdown and ensures accurate readings over time. This is a standard practice in pulse oximetry monitoring.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.