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
Choice A rationale:
Placing a baby on their side to sleep is not recommended due to the risk of sudden infant death syndrome (SIDS) Babies should be placed on their back to sleep to reduce the risk of SIDS. Therefore, this statement indicates a misunderstanding of the teaching and should be corrected by the nurse.
Choice B rationale:
Dressing the baby in lightweight clothing is a correct understanding of SIDS prevention guidelines. Overheating is a risk factor for SIDS, so dressing the baby in lightweight, breathable clothing is recommended to maintain a comfortable body temperature during sleep.
Choice C rationale:
Moving the baby's stuffed animal to the corner of the crib is not a recommended practice. Stuffed animals and soft bedding should be kept out of the baby's sleep area to reduce the risk of suffocation and SIDS. This statement indicates a misunderstanding of the teaching and should be corrected by the nurse.
Choice D rationale:
Having the baby sleep next to the parents in bed increases the risk of accidental suffocation and SIDS. Babies should sleep in their own safe sleep environment, such as a crib or bassinet, to reduce the risk of SIDS. This statement indicates a misunderstanding of the teaching and should be corrected by the nurse.
Correct Answer is C
Explanation
Choice A rationale:
Placing the child on a clear liquid diet for 24 hours following the arterial cardiac catheterization procedure is not necessary. The procedure does not typically require dietary restrictions. However, the healthcare provider may provide specific pre-procedure dietary instructions if needed, but it's not a standard practice.
Choice B rationale:
Instructing the child that they will be on bed rest for 2 days after the procedure is not accurate. While the child may need to rest after the procedure, the duration of bed rest is typically much shorter than 2 days. It's important to provide accurate information to the child to reduce anxiety and promote understanding.
Choice C rationale:
Explaining to the child that they will need to keep their leg straight for 8 hours following the procedure is important and accurate information. Arterial cardiac catheterization often involves the insertion of a catheter through an artery in the leg, and keeping the leg straight helps prevent complications at the insertion site. This information is essential for the child to follow post-procedure instructions correctly.
Choice D rationale:
Telling the child that their dressing will be removed 12 hours after the procedure is not accurate. Dressing removal timing may vary depending on the healthcare provider's protocol, but it's not typically done immediately after the procedure. Providing inaccurate information may lead to confusion and anxiety for the child.
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