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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Nause . Gastrointestinal side effects, such as nausea, vomiting, and diarrhea, are common with cefazolin and other cephalosporin antibiotics.
B. Constipation. Cefazolin is more likely to cause diarrhea rather than constipation.
C. Hypertension. Cefazolin does not typically cause hypertension; hypotension may occur in rare cases due to an allergic reaction.
D. Increased appetite. Cefazolin is not known to increase appetite; gastrointestinal discomfort may actually reduce appetite.
Correct Answer is C
Explanation
A. "Place the infant in a supine position." Infants with heart failure often have difficulty breathing, so placing them in a semi-upright position (e.g., in a car seat or with the head elevated) can help with breathing and reduce cardiac workload.
B. "Allow the infant to sleep through night feedings." Infants with heart failure have increased metabolic demands and may fatigue easily during feedings. Small, frequent feedings (including nighttime feedings) are important to ensure adequate nutrition.
C. "Minimize the infant's environmental stimuli." Excessive stimulation can increase the infant’s metabolic and oxygen demands, worsening heart failure symptoms. Keeping the environment calm and quiet helps reduce stress on the heart.
D. "Bathe the infant every day." While hygiene is important, daily baths can be too exhausting for an infant with heart failure. Instead, bathing should be limited to as needed (e.g., sponge baths) to prevent excessive fatigue.
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