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 D
Explanation
Choice A rationale:
Checking oxygen saturation every 4 hours is a monitoring parameter for patients with respiratory issues but is not the priority in a child with acute epiglottitis. Airway management and infection control are more critical in this situation.
Choice B rationale:
Obtaining a throat culture is important to confirm the diagnosis of epiglottitis. However, initiating isolation precautions and ensuring the child's airway is secure take precedence in the immediate care of a child with acute epiglottitis.
Choice C rationale:
Assisting the child into a supine position is contraindicated in acute epiglottitis. This position can further compromise the airway by obstructing it. The child should be allowed to sit in a position of comfort, usually sitting upright and leaning slightly forward.
Choice D rationale:
Initiating droplet isolation precautions is crucial when dealing with a suspected or confirmed case of epiglottitis. Epiglottitis is highly contagious and is transmitted via respiratory droplets. Isolation precautions help prevent the spread of the infection to others.
Correct Answer is A
Explanation
Choice A rationale:
Lack of sleep is a common trigger that increases the risk of seizures in individuals with a seizure disorder. Sleep deprivation can lower the seizure threshold, making individuals more susceptible to seizures. Educating the guardians about the importance of maintaining a regular sleep schedule for the child can help minimize the risk of seizures.
Choice Brationale:
Decreased temperature is not a common trigger for seizures. In fact, high fever, rather than decreased temperature, is associated with febrile seizures in children. Febrile seizures are triggered by a rapid increase in body temperature.
Choice Crationale:
Exposure to secondhand smoke is a trigger for respiratory issues but is not directly linked to seizures. While it is essential to educate families about the dangers of secondhand smoke, it is not a specific trigger for seizures.
Choice D rationale:
Prolonged headache is not a trigger for seizures. However, it could be a symptom of an underlying neurological issue, and individuals experiencing persistent headaches should seek medical evaluation for proper diagnosis and management.
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