HESI Cystic fibrosis Case Study Darla
20. What laboratory result warrants immediate intervention?
White blood cell count (WBC) is 20,000 mm3.
22. Which action should the primary nurse implement first?
Assess Darla and the child that received the wrong medication.
2. Which documentation further supports the diagnosis of CF?
-A history of frequent respiratory infections. -Reports of foul-smelling stools that have white streaks and are sticky.
11. Which statement by the parents indicates a correct understanding of a proper nutritional protocol of a client with CF?
-Darla's diet should consume more calories than an unaffected child. -Darla should take vitamin A, D, E, and K supplementation along with her diet. -Her diet should consist of 3 meals/day of high fat, high protein, and 2 to 3 snacks/day.
13. What actions should the nurse educator take to address this?
-Teach Darla to take a deep breath and then exhale while whispering the word "huff." -Instruct the parents to perform chest physiotherapy (CPT) either 1 hour before meals or 2 hours after meals, if possible. -Explain the importance of increasing fluid intake during acute exacerbations.
21. At what rate should the nurse set the infusion pump? (Enter numerical value only. If rounding is necessary, round to the whole number.)
30
19. Which intervention should the nurse implement first?
Administer oxygen 6 L/min via simple face mask.
16. Which rationale best supports this referral?
Community resources often provide support groups for parents of children with CF.
23. What nursing task can be safely delegated to the UAP?
Empty the Foley bag.
17. What is the nurse educator's responsibility when discussing immunizations?
Explain that Darla should receive all routine childhood immunizations.
24. What action should the charge nurse take?
Explain that play therapy is an intervention and should not be interrupted for vital signs.
3. What information will the nurse include when teaching about the sweat test?
It is a simple, painless, reliable test that measures the chloride in sweat.
4. Donald and Pamela have been at Darla's bedside since she was admitted to the hospital. Donald asks to speak to the nurse outside in the hall. He tells the nurse that Pamela is telling everyone that Darla is going to be fine and that there has just been a mistake and everything will be all right as long as they pray. *What action should the RN take first?*
Make arrangements to meet with Pamela privately at the first opportunity.
14. Which instruction should the nurse educator give Darla's parents concerning the use of pancreatic enzymes as an oral prescription?
Open the capsules and mix the beads in a nonprotein food such as applesauce.
12. Which instruction indicates to the nurse educator that the parents need more instruction about the respiratory care of the child with CF complications?
Placing Darla in a prone position when she is having a dyspneic episode.
9. Which is the best explanation for the nurse to provide to the student?
Standards of care are published statements that describe the level of care that the client can expect from nurses.
6. Based on her previous conversation with Pamela, what is the best response by the nurse?
"I will sit with Darla so you and your wife can talk. We have a quiet room you can use that is private and close by."
10. Which statement by the nurse is correct?
"It is care such as the sweat test and DNA testing that Darla received."
5. What response reflects that the nurse values the principle of beneficence?
"Pamela, I know this has to be a very scary and difficult time for you. What can I do to help you?"
18. What response is most appropriate by the primary nurse?
"The second MMR is given between 4 and 6 years of age."
1. Which statement by the mother supports the diagnosis of CF?
"When I kiss my daughter, her skin tastes like salt."
7. Which nursing diagnosis has the highest priority?
Altered nutrition: less than body requirements related to poor intestinal absorption.
25. How should the CF nurse educator respond?
Suggest that they add extra salt to Darla's diet and watch her for dehydration.
8. Which statement should the nurse record as the expected outcome for this nursing diagnosis?
The child will be able to remove mucus from the airway by coughing.
15. While discussing pancreatic enzymes, the nurse educator explains that the dosage of the pancreatic enzyme is adjusted according to stool formation, which indicates how well Darla is digesting her food. Which adjustment would the nurse anticipate will be required, if Darla has loose, fatty stools?
The pancreatic enzymes would be increased with each meal and snack.
