Which finding(s) should the nurse expect to assess in a 16-year-old client diagnosed with cystic fibrosis admitted to the hospital for decreased results on pulmonary function tests (PFTs)?
Meconium ileus.
Blood-streaked sputum.
Clear breath sounds bilaterally.
Dyspnea.
The Correct Answer is B
Choice A rationale:
Meconium ileus is a concern in newborns with cystic fibrosis due to thick meconium, which can cause intestinal obstruction. At 16 years old, this complication is not relevant to the client's current condition.
Choice B rationale:
Blood-streaked sputum is a likely finding in a 16-year-old with cystic fibrosis and decreased pulmonary function. Cystic fibrosis leads to mucus accumulation and lung infections, which can cause blood vessels to rupture, resulting in blood-streaked sputum.
Choice C rationale:
Clear breath sounds bilaterally indicate healthy lung function, which is not expected in a client with cystic fibrosis and decreased PFT results. Breath sounds are likely to be diminished due to mucus accumulation.
Choice D rationale:
Dyspnea, or difficulty breathing, is a common symptom in clients with cystic fibrosis and decreased pulmonary function. However, the question asks about the expected findings that the nurse should assess, not a symptom that the client might report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
An increasing pulse rate suggests that the patient's condition is worsening. Tachycardia can indicate increased work of breathing and decreased oxygenation, which are concerning signs in laryngotracheobronchitis.
Choice B rationale:
Mouth breathing is a common response to airway obstruction, such as in laryngotracheobronchitis. While it indicates respiratory distress, it doesn't specifically suggest a worsening of the condition.
Choice C rationale:
An increase in nasal discharge might be seen with the common cold or other upper respiratory infections but is not a specific indicator of worsening laryngotracheobronchitis.
Choice D rationale:
A hoarse cry is a characteristic symptom of laryngotracheobronchitis due to inflammation of the airway. However, it is a common initial symptom and may not directly correlate with worsening of the condition.
Correct Answer is B
Explanation
Choice A rationale:
Replacing the dressing if bleeding is noted is appropriate as it helps maintain a clean and sterile site post-catheterization.
Choice B rationale:
Positioning the child in a flat-lying position immediately after cardiac catheterization is incorrect. The child should be placed in a specific position, such as semi-Fowler's, to avoid complications and promote comfort.
Choice C rationale:
Monitoring the pulses distal to the site is essential to assess circulation and potential complications after the procedure.
Choice D rationale:
Checking the vital signs every 15 minutes is appropriate post-catheterization to detect any hemodynamic changes or complications.
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