a child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment which later finding of

NCLEX-RN

NCLEX RN Practice Questions Quizlet

1. In a pediatric clinic, a nurse is assessing a child recently diagnosed with cystic fibrosis. Which of the following later findings of this disease would the nurse not expect to see at this time?

A. Positive sweat test
B. Bulky greasy stools
C. Moist, productive cough
D. Meconium ileus

Correct answer: C

Rationale: In a child newly diagnosed with cystic fibrosis (CF), noisy respirations and a dry, non-productive cough are typically the first respiratory signs to appear. The other options, including a positive sweat test, bulky greasy stools, and meconium ileus, are among the earliest findings of CF. CF is a genetic condition that affects the production of mucus, sweat, saliva, and digestive juices. Due to a defective gene, these secretions become thick and sticky instead of thin and slippery, leading to blockages in various passageways, especially in the pancreas and lungs. Respiratory failure is a severe consequence of CF, making it crucial to monitor respiratory symptoms closely in affected individuals. Therefore, a moist, productive cough would not be an expected finding in a newly diagnosed child with CF.

2. What is the most common complication of chest wall injury?

A. Hemothorax
B. Atelectasis
C. Pneumonia
D. Pneumothorax

Correct answer: C

Rationale: Pneumonia is the most common complication of chest wall injury. Chest wall trauma can lead to impaired lung function, making patients more susceptible to pneumonia due to reduced ability to clear secretions and impaired breathing. While hemothorax and pneumothorax are potential complications of chest wall injury, pneumonia is more commonly encountered. Atelectasis, although a common pulmonary complication, is not typically the most common complication seen in chest wall injuries.

3. A child is seen in the emergency department for scarlet fever. Which of the following descriptions of scarlet fever is not correct?

A. Scarlet fever is caused by infection with group A Streptococcus bacteria.
B. "Strawberry tongue"? is a characteristic sign.
C. Petechiae occur on the soft palate.
D. The pharynx is red and swollen.

Correct answer: C

Rationale: Petechiae on the soft palate are not a typical finding in scarlet fever. Scarlet fever is caused by group A Streptococcus bacteria, often presenting with a strawberry tongue, red and swollen pharynx, and a sandpaper-like rash. The presence of petechiae on the soft palate is more commonly associated with conditions like rubella rather than scarlet fever. Therefore, this description is not correct in the context of scarlet fever.

4. A patient who has a right-sided chest tube following a thoracotomy has continuous bubbling in the suction-control chamber of the collection device. Which action by the nurse is most appropriate?

A. Document the presence of continuous bubbling.
B. Notify the surgeon of a possible pneumothorax.
C. Take no further action with the collection device.
D. Adjust the dial on the wall regulator to decrease suction.

Correct answer: C

Rationale: Continuous bubbling in the suction-control chamber of the chest tube collection device is an expected finding and indicates that the suction control chamber is connected to suction. It does not necessarily indicate a large air leak, which would be detected in the water-seal chamber. There is no evidence to suggest a pneumothorax based solely on continuous bubbling in the suction-control chamber. Adjusting the suction level by changing the wall regulator setting is not indicated in this situation, as the amount of suction applied is primarily regulated by the water level in the water-seal chamber and not by the vacuum source. Therefore, the most appropriate action in this scenario is for the nurse to take no further action with the collection device.

5. A systolic blood pressure of 145 mm Hg is classified as:

A. Normotensive
B. Prehypertension
C. Stage I hypertension
D. Stage II hypertension

Correct answer: C

Rationale: A systolic blood pressure of 145 mm Hg falls within the range of 140-159 mm Hg, which is classified as Stage I hypertension. Normotensive individuals have a systolic blood pressure less than 120 mm Hg, making choice A incorrect. Prehypertension is characterized by a systolic blood pressure ranging from 120-139 mm Hg, excluding choice B. Stage II hypertension is diagnosed when the systolic blood pressure is greater than 160 mm Hg, making choice D incorrect. Therefore, the correct classification for a systolic blood pressure of 145 mm Hg is Stage I hypertension.