Exhibits
A nurse is reviewing the medical record of a school-age child who has cystic fibrosis. Which of the following findings should the nurse report to the provider?
Heart rate.
WBC count.
HbA1c.
Oxygen saturation.
The Correct Answer is D
Answer is D. Oxygen saturation. The nurse should report the low oxygen saturation of 92% on room air to the provider, as this indicates hypoxemia and respiratory distress in a child with cystic fibrosis. The normal range for oxygen saturation is 95% to 100%¹. Hypoxemia can lead to complications such as pulmonary hypertension, cor pulmonale, and respiratory failure².
A. Heart rate is not the correct answer. The heart rate of 98 beats/min is normal high, but not alarming for a child with cystic fibrosis. The normal range for heart rate in school-age children is 60 to 100 beats/min³. A higher heart rate may be due to fever, infection, dehydration, or anxiety⁴.
B. WBC count is not the correct answer. The WBC count of 10,000/mm3 is within the normal range of 5,000 to 10,000/mm3⁵. A high WBC count may indicate infection or inflammation, which are common in cystic fibrosis⁶.
C. HbA1c is not the correct answer. The HbA1c of 6.5% is borderline for diabetes, but not an urgent finding. The normal range for HbA1c is 4% to 5.6%, and a level of 6.5% or higher indicates diabetes⁷. Cystic fibrosis-related diabetes (CFRD) is a common complication of cystic fibrosis, affecting about 30% of adults with the condition⁸. CFRD requires regular monitoring and treatment with insulin⁹..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Stretch the perineum taut when applying the bag.
Choice A rationale:
Positioning the opening of the bag over both the urethra and the anus is incorrect because it increases the risk of contamination from fecal matter, which can lead to inaccurate test results.
Choice B rationale:
Stretching the perineum taut when applying the bag ensures a secure fit and reduces the risk of leakage, which is essential for accurate urine collection.
Choice C rationale:
Applying lidocaine gel to the perineum before attaching the bag is not recommended as it is unnecessary and could cause irritation or an allergic reaction in the infant.
Choice D rationale:
Placing a snug-fitting diaper over the drainage bag is not the correct action because it can cause the bag to become dislodged or compressed, leading to inaccurate collection or spillage.
Correct Answer is D
Explanation
The correct answer is d. Weight loss 7%.
Choice A reason: Respiratory rate 28/min. The normal respiratory rate for infants can vary depending on their age. For newborns, it’s typically between 30-60 breaths per minute1. As they grow older, the rate decreases. For example, infants aged 0-5 months have a normal respiratory rate of 25-40 breaths per minute. Therefore, a respiratory rate of 28/min falls within the normal range for an infant and does not specifically indicate moderate dehydration.
Choice B reason:. Bradycardia in infants is defined as a heart rate that is slower than normal for their age. For infants aged 0-3 years, a heart rate less than 100 beats per minute is considered bradycardia3. Bradycardia can be a sign of many conditions, including dehydration, but on its own, it is not a definitive indicator of moderate dehydration.
Choice C reason: Capillary refill time is the time taken for color to return to an external capillary bed after pressure is applied to cause blanching. In infants, a normal capillary refill time is less than 2 seconds, and in newborns, it can be up to 3 seconds. A capillary refill time of 1 second is within the normal range and does not indicate moderate dehydration.
Choice D reason: Weight loss 7%. In infants, a weight loss of about 6-9% is generally considered a sign of moderate dehydration. This is because infants are particularly susceptible to fluid loss due to their small body size and higher body water content. A 7% weight loss in an infant who has rotavirus, which can cause significant fluid loss through diarrhea, is a strong indicator of moderate dehydration.
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