Nursing Prioritization, Delegation and Assignment NCLEX Practice Quiz #1

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient’s care? • A. Perform postural drainage and chest physiotherapy every 4 hours. • B. Allow the patient to decide whether she needs aerosolized medications. • C. Place the patient in a private room to decrease the risk of further infection. • D. Plan activities to allow at least 8 hours of uninterrupted sleep. Correct Answer: A. Perform postural drainage and chest physiotherapy every 4 hours. Airway clearance techniques are critical for patients with cystic fibrosis and should take priority over other activities. The Cystic Fibrosis Transmembrane Conductance Regulator defect causes mucus to become dehydrated. Secretions in cystic fibrosis are generally thick, sticky, and more difficult to clear. Frequent airway clearance is a mainstay in the treatment of acute exacerbations, as well as an integral part of health maintenance in cystic fibrosis. • Option B: Although allowing more independent decision-making is important for adolescents, the physiologic need for an improved respiratory function takes precedence at this time. Collaborate with the client and staff to ensure that the schedule for therapy is amenable to all and does not interfere with meals, rest times, or medications. • Option C: A private room may be desirable for the patient but is not necessary. Ensure that clients with CF are not cohorted. The cohorting of clients with CF is not recommended based on published CF Infection Control Consensus Guidelines. • Option D: With increased shortness of breath, it will be more important that the patient has frequent respiratory treatments than 8 hours of sleep. Infection, inflammation, and mucous plugging will cause an increase in the respiratory effort to compensate for airway obstruction. As moving air into and out of the lungs becomes more difficult, the breathing pattern alters to include the use of accessory muscles and retractions.