A nurse is caring for a 7-year-old child who has a fever, tachycardia, and low oxygen saturation. The nurse reviews the child's laboratory results and notes the following:
- WBC count 15,000/mm^3^ (normal range: 5,000 to 10,000/mm^3^)
- Hgb 8 g/dL (normal range: 10 to 15.5 g/dL)
- Hct 32% (normal range: 32% to 44%)
The nurse should suspect that the child has which of the following conditions?
Leukemia.
Sickle cell anemia.
Hemophilia.
Iron deficiency anemia.
The Correct Answer is B
Choice A reason: Leukemia is not a probable condition, as it is a cancer of the white blood cells that causes abnormal proliferation and accumulation of immature or dysfunctional white blood cells. The child has a high WBC count, which can indicate leukemia, but not necessarily. The child does not have other signs of leukemia, such as bleeding, bruising, bone pain, or lymphadenopathy.
Choice B reason: Sickle cell anemia is a possible condition, as it is an inherited disorder that affects the shape and function of the red blood cells, causing them to become sickle-shaped and rigid. The child has a low Hgb and Hct, which can indicate anemia, and a fever, tachycardia, and low oxygen saturation, which can indicate a sickle cell crisis. A sickle cell crisis is a condition where the sickle-shaped red blood cells block the blood flow and cause tissue ischemia and inflammation.
Choice C reason: Hemophilia is not a likely condition, as it is an inherited disorder that affects the clotting factors, causing impaired blood clotting and increased risk of bleeding. The child has a low Hgb and Hct, which can indicate anemia, but not necessarily hemophilia. The child does not have other signs of hemophilia, such as bleeding, bruising, hemarthrosis, or hematuria.
Choice D reason: Iron deficiency anemia is not a definite condition, as it is a type of anemia that occurs when the body does not have enough iron to produce hemoglobin, the protein that carries oxygen in the blood. The child has a low Hgb and Hct, which can indicate iron deficiency anemia, but not necessarily. The child does not have other signs of iron deficiency anemia, such as pallor, fatigue, weakness, or pica.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Continuing to monitor the client is not the best action, as it does not address the low urine output of the child. The child has a urine output of 20 mL/hr, which is below the expected range of 30 to 40 mL/hr for a 3-year-old child. Low urine output can indicate dehydration, kidney injury, or urinary tract obstruction, which require prompt intervention.
Choice B reason: Performing a bladder scan at the bedside is not the most appropriate action, as it is not the first-line diagnostic tool for low urine output. A bladder scan is a noninvasive ultrasound device that measures the amount of urine in the bladder. It can help detect urinary retention, which is the inability to empty the bladder completely. However, urinary retention is unlikely in a 3-year-old child, and a bladder scan may not be accurate or reliable in children.
Choice C reason: Providing oral rehydration fluids is the best action, as it can help restore the fluid and electrolyte balance of the child. Oral rehydration fluids are solutions that contain water, sugar, and salt in specific proportions that match the body's needs. They can prevent or treat dehydration, which is a common cause of low urine output in children. The nurse should offer the child oral rehydration fluids every 15 to 20 minutes, and monitor the urine output, vital signs, and hydration status.
Choice D reason: Notifying the provider is not the first action, as it is not the most urgent or effective intervention for low urine output. The nurse should notify the provider after providing oral rehydration fluids and assessing the child's response. The nurse should also report any signs or symptoms of dehydration, such as dry mucous membranes, sunken eyes, poor skin turgor, or lethargy. The provider may order further tests or treatments, such as blood tests, urine tests, or intravenous fluids.
Correct Answer is A
Explanation
Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.
Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.
Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.
Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.
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