Exhibit 1. Exhibit 2. Provider Prescriptions.
Exhibit 3. Pancrelipase 8,000 units PO with each meal and snack.
Chest physiotherapy three times daily.
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? (Click on the "Exhibit" button for additional information about the client.
There are three tabs that contain separate categories of data.)
Heart rate.
WBC count.
HbA1c.
Oxygen saturation.
The Correct Answer is D
Choice A rationale:
Heart rate is important to monitor but is not specific to the management of cystic fibrosis or the prescribed treatments mentioned in the exhibit. Monitoring heart rate is essential in various clinical situations, but it is not the focus here.
Choice B rationale:
WBC count, or white blood cell count, is a marker of infection or inflammation in the body. While it can be useful in assessing the overall health of a patient, it is not specific to cystic fibrosis or the prescribed treatments mentioned in the exhibit.
Choice C rationale:
HbA1c, or glycated hemoglobin, is a marker used in diabetes management to assess long-term blood sugar control. It is not relevant to cystic fibrosis or the medications prescribed in this case.
Choice D rationale:
Oxygen saturation is a crucial parameter to monitor in a child with cystic fibrosis, especially considering the respiratory complications associated with this condition. Low oxygen saturation levels can indicate respiratory distress, which needs prompt medical attention. Reporting any abnormal oxygen saturation values to the provider ensures timely intervention and appropriate management of the child's respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"The test will measure the amount of chloride in your baby's sweat." Pilocarpine iontophoresis testing is used to diagnose cystic fibrosis by measuring the chloride content in the patient's sweat. Cystic fibrosis patients have elevated chloride levels in their sweat, which is a characteristic feature of the disease. Educating the parents about the purpose of the test helps them understand its significance in diagnosing their baby's condition.
Choice B rationale:
"We will measure the amount of protein in your baby's urine over a 24-hour period." Measuring protein in urine over a 24-hour period is a test for kidney function, not for cystic fibrosis. This statement is unrelated to the pilocarpine iontophoresis testing and may confuse the parents about the purpose of the procedure.
Choice C rationale:
"Your baby will need to fast for 8 hours prior to the test." Fasting is not a requirement for pilocarpine iontophoresis testing. This statement is incorrect and could cause unnecessary stress for the parents and the infant. It is essential to provide accurate information to ensure that the parents are well-prepared for the procedure.
Choice D rationale:
"A nurse will insert an IV prior to the test." Inserting an IV is not a part of the pilocarpine iontophoresis testing procedure. This statement is inaccurate and does not contribute to the parents' understanding of the test. Providing irrelevant information can create confusion and anxiety, which should be avoided during patient education.
Correct Answer is C
Explanation
The correct answer is C. Blood pressure 118/74 mm Hg.
Choice A reason: The respiratory rate of 26 breaths per minute is within the normal range for a 2-year-old child, which is typically 20-30 breaths per minute1. Therefore, this finding does not need to be reported to the provider.
Choice B reason: A pulse rate of 98 beats per minute is also within the normal range for a 2-year-old, which is 90-140 beats per minute. This is a typical finding and does not require reporting to the provider.
Choice C reason: The blood pressure reading of 118/74 mm Hg is higher than the normal range for a 2-year-old, which should be approximately 86-106/42-63 mm Hg. This elevated blood pressure should be reported to the provider as it may indicate an underlying health issue.
Choice D reason: A temperature of 37.2°C (99° F) is at the upper limit of the normal range for body temperature in children and is not typically a cause for concern unless there are other signs of illness1. This temperature does not need to be reported to the provider.
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