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The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in either of their families has CF. What is the nurse's best response based on the understanding of CF?
- A. Only one parent carries the CF gene.
- B. Both parents are carriers of the CF gene.
- C. The inheritance pattern is multifactorial.
- D. The result is probably a genetic mutation.
Correct Answer: B
Rationale: Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the disease.
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The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would indicate the child is experiencing increased respiratory obstruction?
- A. Restlessness
- B. Tachycardia
- C. Brassy cough
- D. Expiratory wheezing
Correct Answer: A
Rationale: Restlessness is a primary sign of increased respiratory obstruction.
Which is the most appropriate nursing action when planning care for a child with cystic fibrosis?
- A. Provide chest physiotherapy before meals every day.
- B. Assess weight monthly.
- C. Administer pancreas with protein food at mealtime.
- D. Ensure high-protein, high-calorie diet.
Correct Answer: D
Rationale: The maintenance of adequate nutrition is essential. The diet is high in protein and calories.
When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the nurse immediately report?
- A. Respiration rate decreases from 40 to 32 breaths/minute
- B. Heart rate decreases from 110 to 100 beats/minute
- C. Quiet chest' from previous assessment of wheezing
- D. Oxygen saturation of 90%
Correct Answer: C
Rationale: A 'quiet chest' after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest.
The nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A). What might this indicate?
- A. Bleeding from the surgical site
- B. Pain at the incision area
- C. Sore throat from postnasal drip
- D. Potential vomiting
Correct Answer: A
Rationale: Hemorrhage is the most common postoperative complication. Blood trickling down the back of the child's throat could cause frequent swallowing.
The nurse offers a variety of fluids to a 5-year-old asthmatic child to compensate for the fluid loss through dyspnea. Which fluids are most appropriate?
- A. Room temperature water
- B. Carbonated beverages
- C. Iced fruit juice
- D. Cold milk
Correct Answer: A
Rationale: Room temperature fluids are the best. Carbonated and iced beverages increase spasm.