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? 

Choice A rationale:

Weighing the child once each month is not the most relevant information to include in teaching parents of a preschool-age child with heart failure. Monitoring weight is important, but it should be done more frequently, preferably daily, to track any sudden weight gain, which could indicate fluid retention and worsening heart failure.

Choice B rationale:

Withholding digoxin if the child's pulse is greater than 100/min is not appropriate. Digoxin is commonly prescribed for heart failure in pediatric patients to strengthen the heartbeat. Instead, the nurse should teach the parents to monitor the child's pulse rate regularly and report any significant changes to the healthcare provider.

Choice C rationale:

Increasing the child's oxygen flow rate until the child no longer has cyanosis is incorrect. While oxygen therapy might be necessary for a child with heart failure, adjusting the oxygen flow rate based on cyanosis is not the appropriate approach. Oxygen therapy should be prescribed and monitored by healthcare providers based on the child's oxygen saturation levels.

Choice D rationale:

Providing for periods of rest is the correct choice. Children with heart failure often tire easily due to the heart's reduced ability to pump blood effectively. Allowing the child to rest helps conserve energy and prevents additional strain on the heart. This instruction promotes the overall well-being and comfort of the child, aligning with the management of heart failure.

Choice A rationale:

Check the toddler's ID band against the medical record. Verifying the toddler's identity through their ID band is a standard and reliable practice in healthcare settings. It ensures that the right medication is administered to the right patient, promoting patient safety and preventing medication errors. Checking the ID band against the medical record is a fundamental step in the medication administration process.

Choice B rationale:

Ask another nurse to confirm the toddler's identity. While collaboration and double-checking are important in healthcare settings, the primary responsibility lies with the nurse administering the medication. Relying solely on another nurse to confirm the toddler's identity could lead to errors. Nurses should follow established protocols, including checking the ID band, to maintain patient safety.

Choice C rationale:

Check the toddler's room number against their ID band. Verifying the room number is not a reliable method of confirming a patient's identity. Room assignments can change, and patients can be moved to different locations within the healthcare facility. Relying on room numbers can lead to confusion and errors in identifying patients.

Choice D rationale:

Ask the parent to confirm the toddler's identity. While involving parents in the care process is important, the primary responsibility for confirming a patient's identity lies with the healthcare provider. Parents can assist by providing information, but the final verification should be done through established healthcare protocols, such as checking the ID band against the medical record.