A nurse is caring for a pediatric client who is receiving pancreatic enzyme replacement therapy. Which nursing action measures the effectiveness of the therapy?
Monitoring the stool consistency.
Checking the pupillary reflex response.
Listening to breath sounds.
Auscultating the apical pulse rate.
The Correct Answer is A
Choice A rationale:
Monitoring the stool consistency is a crucial nursing action to assess the effectiveness of pancreatic enzyme replacement therapy. Patients with pancreatic insufficiency, such as those with cystic fibrosis, may have difficulty digesting fats properly. Improved stool consistency, specifically a reduction in greasy and foul-smelling stools, indicates that the pancreatic enzymes are aiding in fat digestion.
Choice B rationale:
Pupillary reflex response assessment is unrelated to pancreatic enzyme replacement therapy. It is more commonly performed to assess neurological status or the effects of medications affecting the autonomic nervous system.
Choice C rationale:
Listening to breath sounds is important for assessing respiratory status, but it does not directly reflect the effectiveness of pancreatic enzyme replacement therapy.
Choice D rationale:
Auscultating the apical pulse rate is a general assessment of cardiovascular function and does not provide information about the effectiveness of pancreatic enzyme replacement therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Administering a bolus of intravenous (IV) fluids might be necessary for severe dehydration, but in mild dehydration, oral rehydration is preferred as it avoids potential complications associated with IV fluids.
Choice B rationale:
Offering clear fluids, popsicles, and gelatin is appropriate, but this choice does not specifically address rehydration, which is the primary concern in mild dehydration.
Choice C rationale:
Offering oral rehydration solution (ORS) in small, frequent amounts is the most appropriate intervention for mild dehydration secondary to diarrhea. ORS contains the right balance of electrolytes and fluids to rehydrate without overwhelming the gastrointestinal tract.
Choice D rationale:
Keeping the child on a strict BRAT diet (bananas, rice, applesauce, toast) is an outdated approach. While BRAT foods can be tolerated during mild illness, they lack the necessary electrolytes and fluids to effectively rehydrate.
Correct Answer is D
Explanation
Choice A rationale:
Examining for the presence of any flexion of the hips when the infant is lying on the abdomen is a method to assess for Ortolani and Barlow signs, which indicate hip dislocation, not hip dysplasia.
Choice B rationale:
Extension of the legs while stimulating the stepping reflex is a normal developmental response and is not specific to hip dysplasia.
Choice C rationale:
The Babinski reflex is related to neurological development and not directly linked to hip dysplasia.
Choice D rationale:
Asymmetrical gluteal folds and unequal leg length are common findings in congenital hip dysplasia. Hip dysplasia involves improper formation of the hip joint, leading to instability and deformity of the hip socket, which can result in these physical characteristics.
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