the nurse is caring for a 3 year old child who has been recently diagnosed with cystic fibrosis which discharge instruction by the nurse is most impor
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Nursing Elites

HESI RN

Pediatric HESI Quizlet

1. The nurse is caring for a 3-year-old child who has been recently diagnosed with cystic fibrosis. Which discharge instruction by the nurse is most important to promote pulmonary function?

Correct answer: B

Rationale: In cystic fibrosis, thick mucus obstructs the airways, making it difficult to clear from the lungs. Cough suppressants can help reduce the discomfort associated with persistent coughing, allowing the child to cough more effectively to clear the mucus, thus promoting pulmonary function. Chest physiotherapy, not exercise, helps mobilize the mucus. Oxygen therapy may be needed but is not the most important for promoting pulmonary function in this case.

2. When reviewing developmental changes with the parents of a 6-month-old infant, what information should the practical nurse reinforce?

Correct answer: C

Rationale: The correct answer is C because providing a developmentally safe environment for a 6-month-old infant is crucial as they begin to explore their surroundings more actively. This includes ensuring that the environment is free of hazards and that the infant is supervised to prevent accidents. Choice A is incorrect because self-feeding finger foods may not be developmentally appropriate for a 6-month-old infant. Choice B is incorrect as most infants are able to sit up with support around 6 months of age without the need for specific teaching strategies. Choice D is also incorrect as while appetite changes can occur, explaining a specific increase in appetite over the next 6 months is not a primary focus when discussing developmental changes with parents of a 6-month-old.

3. A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

Correct answer: B

Rationale: Administering the scheduled dose is appropriate in this scenario. The nurse obtained an apical heart rate of 128 bpm, which is within the expected range for a 2-year-old child. Therefore, there is no immediate concern to withhold the scheduled dose of digoxin. Determining the pulse deficit is not necessary as the heart rate is appropriate. Calculating the safe dose range is not needed as the current dose is within the therapeutic range. Reviewing the serum digoxin level may be indicated later for monitoring but is not urgent based on the heart rate assessment. Administering the scheduled dose of digoxin is the correct action at this time.

4. A mother brings her 3-week-old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life-threatening complication?

Correct answer: D

Rationale: Crying without tears is a sign of severe dehydration, which is a potentially life-threatening complication in infants with projectile vomiting. Dehydration can rapidly progress in infants, leading to serious consequences if not promptly addressed. The combination of projectile vomiting, listlessness, and absence of tears when crying should raise concerns about severe dehydration and the need for urgent intervention to prevent further complications.

5. What action should the nurse take when a child presents with fever, sore throat, swollen red spots, and fluid-filled blisters?

Correct answer: D

Rationale: When a child presents with fever, sore throat, swollen red spots, and fluid-filled blisters, it may indicate a contagious viral infection. In such cases, implementing transmission precautions is crucial to prevent the spread of the infection to others in the pediatric clinic or community. Obtaining a fluid culture from the blisters (Choice A) may not be necessary at the initial stage without knowing the cause of the infection. Administering a fever-reducing medication (Choice B) may help manage symptoms but doesn't address the need for preventing transmission. Covering the drainage vesicles with a dressing (Choice C) may provide comfort to the child but does not directly address the risk of transmission to others.

Similar Questions

A two-year-old child with heart failure is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
The nurse is planning for a 5-month-old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother?
The caregiver is caring for a 3-year-old child with a diagnosis of gastroenteritis. The child has had several episodes of vomiting and diarrhea over the past 24 hours. What is the caregiver's priority assessment?
A 2-year-old child is admitted with severe dehydration due to gastroenteritis. Which assessment finding indicates that the child's condition is improving?
The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?

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