The nurse assesses a client with a history of cystic fibrosis who is being admitted due to a pulmonary exacerbation. Which assessment finding requires immediate action by the nurse?

Question

Quizplus · Accepted Answer

11ecbb05_ca73_09c7_b433_b72a1e7c88ae_MD0009_00 Cystic fibrosis (CF) is a genetic disorder in which a defective protein causes the exocrine glands to produce thick and sticky secretions that can plug small airways and ducts (eg, gastrointestinal tract). Respiratory manifestations include ineffective airway clearance, risk of infection, and eventually chronic lung disease (bronchiectasis). CF also damages alveoli, which can burst suddenly, resulting in pneumothorax and need for chest tube placement. Clients with CF often have low baseline oxygen saturation; however, a sudden drop in SpO₂ (eg, from 92% to 88% on room air) indicates a possible mucus plug airway obstruction and the need for urgent intervention (eg, physiotherapy, mucolytic medications) (Option A). (Option B) Pulmonary capillaries can be damaged during CF exacerbations, resulting in hemoptysis (bloody sputum). Gross hemoptysis (eg, frank blood) can be life threatening; however, blood-tinged sputum is not a priority finding. (Option C) Impaired secretion of digestive enzymes results in malabsorption of essential nutrients. In addition, many clients have a poor appetite. Maintaining weight is important; however, oxygenation is the priority. (Option D) Although impaired digestion and absorption cause frequent steatorrhea (fatty stool) episodes, clients with CF can develop distal intestinal obstruction syndrome (DIOS) from dehydrated, thickened mucus and stool. DIOS causes constipation and abdominal discomfort that can be resolved by rehydrating the stool (eg, polyethylene glycol). Educational objective: Clients with cystic fibrosis are at risk for respiratory infection, mucus plugs, and pneumothorax. When respiratory status suddenly declines (eg, drop in SpO₂), urgent intervention (eg, physiotherapy, chest tube) is required to resolve mucus plug airway obstruction.

The Nurse Assesses a Client with a History of Cystic