A nurse is admitting an 8-year-old child to the pediatric unit.
A nurse is reviewing the child's electronic medical record (EMR). Which of the following findings should the nurse identify as requiring immediate follow-up? Select the 5 findings that require immediate follow-up.
Neurologic assessment
Hemoglobin
Peripheral pulses
WBC
Glucose
Abdominal assessment
Pain assessment
Temperature
Correct Answer : A,B,D,F,H
A. Neurologic assessment. Neurologic changes can indicate worsening infection, sepsis, or other serious conditions, requiring immediate follow-up.
B. Hemoglobin. The child's hemoglobin level (9.5 g/dL) is below the normal range (10 to 15.5 g/dL), indicating anemia, which requires monitoring and possible intervention.
C. Peripheral pulses. There is no indication of circulatory compromise or perfusion issues in the given data.
D. WBC. The elevated WBC count (14,000 mm³) suggests an active infection or inflammation, which requires immediate follow-up.
E. Glucose. The glucose level (90 mg/dL) is within normal limits and does not require immediate attention.
F. Abdominal assessment. If the child has an infection, especially a serious bacterial infection, monitoring for abdominal distension, tenderness, or signs of peritonitis is crucial.
G. Pain assessment. While pain assessment is always important, it does not require immediate follow-up unless there are specific pain-related concerns in the provided data.
H. Temperature. Fever is a key sign of infection. Monitoring the child’s temperature is crucial in identifying worsening infection or sepsis.
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Related Questions
Correct Answer is D
Explanation
A. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
Correct Answer is B
Explanation
A. "Monitor for constipation." Constipation is not a common adverse effect of gentamicin. More concerning side effects include nephrotoxicity and ototoxicity.
B. "Maintain strict I&O." Gentamicin can cause nephrotoxicity, so it is essential to monitor intake and output (I&O) closely to assess kidney function and detect early signs of renal impairment.
C. "Initiate airborne precautions." Gentamicin is an antibiotic and does not require airborne precautions. Airborne precautions are used for infections like tuberculosis, measles, and varicella.
D. "Encourage bed rest." Gentamicin does not require bed rest. However, if the child experiences dizziness due to ototoxicity (another adverse effect), activity may need to be limited.
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