Unit 2: NR328 - Nursing Care: Cystic Fibrosis

Place the activities to improve oxygenation in the order they should be performed by the nurse.​

1.) Elevate HOB 2.) Huff coughing 3.) administers bronchodilators as needed PRN 4.) administer O2

The nurse is caring for a family and child who is newly diagnosed with cystic fibrosis in an acute care setting. Which professionals could the nurse consult to support the client and family? Select all that apply.​

ALL

The nurse is caring for a teenaged client with cystic fibrosis who is stable and receiving antibiotic treatment for an infection. Which accommodation(s) may the nurse make for this client? Select all that apply.​

Allow client to have undisturbed sleep from 2200 to 0600​ Allow client's parents or friends to bring in favorite foods for meals Make client's favorite snacks from ingredients in the unit kitchen

The nurse is caring for a newly admitted adolescent client with cystic fibrosis exacerbation. The client presented with a report of increased difficulty breathing and green mucus expectoration. Indicate whether the health care provider orders are anticipated or contraindicated by the nurse. ​

Anticipated - ADEK vitamins 1 tab twice daily, High-calorie, high-protein diet with snacks three times a day​ Manual chest physical therapy four times daily​ Sputum culture and sensitivity​ Contraindicated - bedrest

The nurse is caring for an adolescent with cystic fibrosis. The client has been losing weight and having increased incidence of steatorrhea. Indicate whether each assessment question is applicable or not applicable to gathering information related to the problem. ​

Applicable - "Can you tell me how you usually take your enzymes with meals?​" "Can you tell me how you usually take your enzymes with snacks?​" "Can you tell me about times when you might not take your enzymes?"​ "Can you tell me what you ate yesterday?​" "Where do you store your enzymes?​" Not applicable - "Can you tell me about times when you might share food with friends?"​ "When was the last time you ate ice cream?​"

The nurse and respiratory therapist are planning care for a client with cystic fibrosis on an acute pediatric unit. When are the best times for the team to plan for high-frequency chest compression? Select all that apply.​

At least 2 hours after a meal​ At bedtime​ In the morning​ Right before a meal​

Which scenario will most likely result in a child having cystic fibrosis (CF)? ​

Both parents are mutated gene carriers, and each passes the mutated gene to the child​

Which are the top 4 assessment findings that require follow up by the nurse? Select 4 items only.

Breath sounds​ Respiratory rate​ Pulse oximetry​ Thick, green sputum​

Which diagnostic tests are used to confirm the diagnosis of cystic fibrosis? Select all that apply.​

Cystic fibrosis transmembrane regulator (CFTR) mutation Sweat chloride test Newborn screening test

Highlight the assessment findings that indicate the nursing actions were effective in improving respiratory status.

Large amount of mucus expectorated, Breath sounds clear to upper lobes, R 22, pulse oximetry 98%

For each finding, indicate if the finding is consistent with clinical manifestations of pneumonia or pneumothorax. Each finding may support pneumonia, pneumothorax, or both. ​

Pneumonia - ALL Pneumothorax- ALL but thick, green sputum

Which systems are affected by cystic fibrosis? Select all that apply.​

Respiratory system​ Gastrointestinal system​ Endocrine system​ Integumentary system​ Reproductive system

For each nursing action, indicate if the action supports the goal of preventing infection, maintaining oxygenation, or improving nutrition status. ​

Treat and prevent infection - Administer antibiotics as prescribed​ Ambulate four times a day​ Perform airway clearance therapy​ Promote oxygen - Ambulate four times a day​ Perform airway clearance therapy​ Improve nutrition status - Administer pancrelipase​ Administer vitamins A, D, E, and K​ Provide preferred snacks​

The highest priority is to --- and the next highest priority is to ---

improve oxygen, treat the infection

When caring for clients with cystic fibrosis who are discharged from the hospital with prescriptions for intravenous antibiotics, the medications are administered by the family or home health nursing via a --- or a(n) ---

peripherally inserted central catheter, implanted port

The nurse is caring for an adolescent client with cystic fibrosis during a routine appointment with the pulmonologist. For each assessment finding, indicate whether it supports the nursing diagnosis of disturbed body image, ineffective self-health management, activity intolerance, or dysfunctional gastrointestinal motility. Each assessment finding may support more than one nursing diagnosis.​

small stature - distrubed body image refusal to adhere to treatment regimen - ineffective self-health management shortness of breath - activity intolerance incidience of steatorrhea at school - disturbed body image, dysfunctional GI motility