a nurse is providing care to a child with a diagnosis of cystic fibrosis what is the priority nursing intervention
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Nursing Elites

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Pediatric HESI Test Bank

1. When caring for a child diagnosed with cystic fibrosis, what is the priority nursing intervention?

Correct answer: A

Rationale: The priority nursing intervention when caring for a child with cystic fibrosis is administering pancreatic enzymes. Cystic fibrosis is a genetic disorder that affects the digestive and respiratory systems. Administering pancreatic enzymes is crucial in aiding digestion as patients with cystic fibrosis often have pancreatic insufficiency. While providing respiratory therapy and encouraging physical activity are important aspects of care for individuals with cystic fibrosis, administering pancreatic enzymes takes precedence in addressing the malabsorption issues associated with the condition. Encouraging frequent handwashing is also essential in infection control, but it is not the priority intervention specifically related to managing cystic fibrosis.

2. When caring for a 2-year-old girl who is wheezing and has difficulty breathing, which interview question would provide the most useful information related to the symptoms of the child?

Correct answer: D

Rationale: Asking the parents if they smoke in the home is the most relevant question as exposure to secondhand smoke can exacerbate respiratory symptoms like wheezing and difficulty breathing in children. This information is crucial for identifying potential triggers for the child's symptoms. Inquiring about child safety in the home, asking about the child's temperament, and inquiring about the child's diet, while important aspects of care, may not directly address the respiratory symptoms the child is experiencing.

3. During the health assessment of a school-age child, on which problem would the nurse focus more attention based on the child's developmental level?

Correct answer: D

Rationale: During the school-age years, children are more physically active and curious, which increases their risk of accidents and injuries. This developmental stage is characterized by increased exploration and engagement in physical activities. While infections and poisonings are important health concerns, school-age children are more likely to be affected by accidents and injuries due to their active nature. Risk-taking behaviors may become more prevalent in adolescence rather than during the school-age period, making it a less likely focus for the nurse during the health assessment of a school-age child.

4. After a cardiac catheterization, what is the priority nursing care for a 3-year-old child?

Correct answer: B

Rationale: The priority nursing care after a cardiac catheterization in a 3-year-old is to monitor the site for bleeding. This is essential to promptly detect and manage any potential complications, such as hematoma or hemorrhage. Encouraging early ambulation, as mentioned in choice A, may not be safe immediately post-procedure and should be guided by the healthcare provider's instructions. Restricting fluids until blood pressure is stabilized, as in choice C, is not typically necessary after a cardiac catheterization. Comparing blood pressure in both lower extremities, as in choice D, is not the priority immediate nursing care following this procedure.

5. .A nurse is caring for an infant whose vomiting is intractable. For what complication is it most important for the nurse to assess?

Correct answer: B

Rationale: Intractable vomiting can lead to alkalosis due to loss of stomach acids.

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