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 C
Explanation
Choice A rationale:
Providing a high-calorie, low-protein diet is not directly related to the management of osteomyelitis. However, proper nutrition is essential for overall healing and immune function.
Choice B rationale:
Encouraging frequent physical activity to increase bone mass is not appropriate for a child with osteomyelitis. Physical activity can worsen the condition and cause further damage to the affected bone.
Choice C rationale:
Maintaining a patent intravenous catheter is important for administering intravenous antibiotics, which are the mainstay of treatment for osteomyelitis. Ensuring that the catheter is functional and infection-free is crucial for the delivery of appropriate antibiotics to combat the infection.
Choice D rationale:
Initiating contact precautions is not necessary for osteomyelitis. Osteomyelitis is not typically spread through direct contact but results from the spread of bacteria through the bloodstream to the affected bone.
Correct Answer is A
Explanation
Choice A rationale:
Assess respiratory status. In a child with a head injury, assessing respiratory status is the top priority. Respiratory distress or compromise could indicate potential brain injury or other serious complications. Ensuring an open airway, adequate breathing, and proper oxygenation is essential for the child's immediate well-being. Any signs of respiratory distress should be promptly addressed to prevent further complications.
Choice B rationale:
Check pupil reactions. Checking pupil reactions is important in assessing neurological function, but it is secondary to assessing respiratory status in this scenario. Respiratory status takes precedence because impaired breathing can lead to hypoxia, which can further compromise neurological function. Once respiratory status is stabilized, assessing neurological signs, including pupil reactions, becomes crucial to evaluate potential brain injury.
Choice C rationale:
Inspect for fluid leaking from the ears. Inspecting for fluid leaking from the ears is important in head injury assessment, specifically for signs of cerebrospinal fluid leakage. However, it is not the first action to take. Assessing respiratory status and ensuring proper oxygenation are immediate
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