PN Cystic Fibrosis HESI Case Study

Which statement by the PN is correct?

A. "It is care such as vision, hearing, and scoliosis screening that Maria will get when she starts school."

Which documentation in Maria's medical record further supports the suspected diagnosis of CF?

A. A history of frequent respiratory infections.

While Maria's mother is discussing with the PN what she learned from the nurse educator, the PN recognizes which statement indicates a correct understanding of the etiology of CF?

A. Both Maria's biological parents must have the CF gene for Maria to get it.

Which rationale best supports this referral?

A. Community resources often provide support groups for parents with children with CF.

Which action should the PN implement first?

A. Determine if Maria is having any reactions or adverse effects.

What is the PN's responsibility when reviewing immunizations?

A. Explain that Maria should receive all routine childhood immunizations.

Which explanation should the PN provide?

A. Standards of care are published statements that describe the level of care that the client can expect.

What action should the PN take to address this?

A. When Maria is old enough, teach her to take a deep breath and then exhale while whispering the word "huff."

What is the best response by the PN?

B. "I will sit with Maria so you and your wife can talk. We have a quiet room you can use that is private and close by."

How should the PN respond?

B. "The second MMR is given when Maria is between 4 and 6 years of age."

Which action by the PN is warranted?

B. Document the observations, but take no action at this time.

What nursing task can be safely assigned to the UAP?

B. Emptying a foley bag.

What action should the PN take?

B. Inform the RN that the infusion rate is too high.

What reinforcement should the PN give to Maria's parents?

B. Remind them to add extra salt to Maria's diet and watch her for dehydration.

The PN recognizes that which laboratory result warrants immediate intervention?

B. White blood cell (WBC) count is 20,000/mm3.

What is the best response by the PN?

C. "Toys and games are used to help with Maria's physical and emotional needs."

Which statement made by the mother should the practical nurse (PN) recognize that supports the suspected diagnosis of Cystic Fibrosis (CF)?

C. "When I kiss my daughter, her skin tastes like salt."

Which intervention should the PN review with Maria's parents concerning the child's level of activity?

C. Discuss the importance of playing games that require Maria to do physical activity such as running and jumping.

Which adjustment will be required if Maria has loose, fatty stools?

C. Increase the pancreatic enzymes with each meal and snack.

Which information should the PN reinforce with Maria's parents concerning the use of pancreatic enzymes as an oral prescription? (Select all that apply.)

C. Open the capsules and mix the beads in a food like applesauce. E. Store the enzymes at room temperature away from extreme heat or cold.

Which statement should the PN find as the expected outcome for this nursing diagnosis?

C. The child will be able to remove mucus from the airway by coughing.

Which response reflects that the PN values the principle of beneficence?

D. "Wendy, I know this has to be a very scary and difficult time for you. What can I do to help you?"

Which intervention should the PN implement first?

D. Administer oxygen 2 L/min via pediatric face mask.

Which nursing diagnosis would the PN expect to have the highest priority?

D. Altered nutrition: less than body requirements related to poor intestinal absorption.

Which action(s) should the PN reinforce when discussing respiratory complications? (Select all that apply.)

D. Chest percussion and postural drainage 4 times a day. E. Clearing of retained secretions from the child's mouth.

What action should the PN take?

D. Delay taking vital signs until play therapy is over.

What information should the PN include when reviewing information about the sweat test to Maria's mother?

D. It is a simple, painless, reliable test that measures the chloride in sweat.

What action should the PN take first?

D. Make arrangements to meet with Wendy privately at the first opportunity.