A young adult patient with cystic fibrosis (CF) is admitted to the hospital with increased dyspnea. Which intervention should the nurse include in the plan of care?
Ask the Health Care Provider to order a sweat chloride test.
Coordinate with the dietitian to place the patient on a low-sodium diet.
Coordinate with respiratory therapy to perform chest physiotherapy
Coordinate with the case manager to arrange for a hospice nurse visit.
The Correct Answer is C
Choice A reason: Sweat chloride tests diagnose CF, not manage dyspnea in a known patient. It’s irrelevant here, as the focus is treating acute respiratory symptoms, not reconfirming an established diagnosis in this scenario.
Choice B reason: Low-sodium diets aren’t indicated for CF; patients need high salt due to losses. Dyspnea stems from mucus obstruction, not fluid, so this intervention contradicts CF physiology and symptom management.
Choice C reason: Chest physiotherapy clears mucus in CF, improving airflow and reducing dyspnea. It targets the primary cause—thick secretions—enhancing lung function, a standard intervention coordinated with respiratory therapy for acute exacerbations.
Choice D reason: Hospice is premature for dyspnea in CF without end-stage decline. It’s inappropriate now, as active interventions like physiotherapy address reversible symptoms, prioritizing treatment over palliative care planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Pleural effusion with chest discomfort suggests fluid buildup, causing pain but not immediate airway compromise. It’s stable compared to tracheal deviation, prioritizing respiratory distress over this less acute issue.
Choice B reason: Cor pulmonale with 4+ edema indicates chronic right heart failure, a serious but slower process. It’s less urgent than acute airway obstruction, as it’s manageable with diuretics, not an immediate threat.
Choice C reason: Tracheal deviation post-catheter insertion signals tension pneumothorax, a life-threatening emergency. It compresses airways and vessels, requiring immediate assessment and intervention to restore breathing and circulation.
Choice D reason: Fever of 101°F post-lung transplant suggests infection or rejection, critical but not airway-immediate. It’s urgent, yet tracheal deviation’s acute respiratory collapse takes precedence over this systemic concern.
Correct Answer is B
Explanation
Choice A reason: Metabolic alkalosis shows pH >7.45 with HCO3- >26 mEq/L from base excess. Here, pH is 7.48, but HCO3- is normal at 24 mEq/L, ruling out metabolic cause. PaO2 of 55 mmHg indicates hypoxemia, but the primary issue isn’t metabolic.
Choice B reason: Respiratory alkalosis occurs with pH >7.45 and PaCO2 <35 mmHg from hyperventilation. Here, pH is 7.48, PaCO2 is 28 mmHg, and HCO3- is normal, confirming respiratory etiology. PaO2 of 55 mmHg shows hypoxemia, matching this acute ventilatory pattern.
Choice C reason: Metabolic acidosis has pH <7.35 and HCO3- <22 mEq/L from acid gain. Here, pH is 7.48 and HCO3- is 24 mEq/L, contradicting acidosis. PaO2 of 55 mmHg indicates hypoxemia, but the acid-base status is alkalotic, not acidic.
Choice D reason: Respiratory acidosis features pH <7.35 and PaCO2 >45 mmHg from CO2 retention. Here, pH is 7.48 and PaCO2 is 28 mmHg, showing CO2 loss, not retention. Hypoxemia (PaO2 55 mmHg) is present, but the pattern is alkalotic.
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