A nurse is planning care for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?
Decrease pancreatic enzymes if steatorrhea develops.
Limit fluid intake to 750ml per day.
Increase fat content in the child's diet to 40% of total calories.
Administer pancreatic enzymes 2 hr after meals.
The Correct Answer is C
A. Pancreatic enzymes should not be decreased for steatorrhea; they are required to help with digestion.
B. Fluid intake should not be restricted; hydration is important for children with cystic fibrosis.
C. Children with cystic fibrosis need a high-calorie, high-fat diet due to malabsorption of nutrients and increased energy needs.
D. Pancreatic enzymes should be administered with meals, not two hours after.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A urinary output of 100 mL/hr is within the expected range for a 10-year-old and does not indicate septic shock. In early septic shock, urinary output is often preserved or mildly decreased.
B. An elevated temperature (fever) is a hallmark of early septic shock as the body mounts an inflammatory response to infection. Fever often accompanies early sepsis in pediatric patients.
C. Blood pressure may remain normal or slightly elevated in early septic shock due to compensatory mechanisms. A BP of 130/90 mm Hg is not a defining feature.
D. A heart rate of 60/min is abnormally low for a 10-year-old and could indicate late-stage shock or other complications. In early septic shock, tachycardia (elevated heart rate) is typically observed.
Correct Answer is C
Explanation
A. While the nurse is required to report, it is not the supervisor’s decision. The nurse should clarify that they are the mandated reporter.
B. Deferring the explanation to the supervisor avoids the nurse’s responsibility. The nurse should directly explain their duty.
C. Nurses are mandated reporters and are legally required to report suspected child abuse. This response is appropriate as it aligns with the nurse’s professional and legal responsibilities.
D. The nurse should address the issue, not refer to the provider for an explanation of their actions.
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