A nurse is caring for a school-age child.
Which of the following assessment findings should the nurse report to the provider?
Select the 4 findings that the nurse should report to the provider.
Oral intake
Blood pressure
Temperature
Oxygenation
Gastrointestinal status
Sputum
Pain
Respiratory effort
Correct Answer : B,D,E,H
A. While the child’s oral intake is reduced, it is not as immediately critical as the other findings. However, it should still be monitored and managed.
B. The child’s blood pressure has dropped to 88/48 mm Hg on Day 3, which is significantly lower than the initial value and may indicate hypotension. This could be a sign of worsening condition or dehydration and needs to be reported for further evaluation and intervention.
C. The temperature of 38.1° C (100.6° F) on Day 3 indicates a fever but is lower than the initial admission temperature. It is important but not as critical as the other findings in this scenario.
D. The oxygen saturation has decreased to 88% on room air, which is below the normal range and indicates hypoxemia. This is critical in a patient with pneumonia and cystic fibrosis, and it requires immediate attention to manage respiratory function and oxygenation.
E. The child has passed three large, frothy, foul-smelling stools, which could be indicative of a gastrointestinal complication, possibly related to cystic fibrosis. This change in bowel habits should be reported as it may impact the child’s overall condition and treatment plan.
F. The sputum is thick, yellow, and blood-streaked, which is consistent with the condition but does not require immediate reporting unless there is a significant change in color or consistency.
G. The reported pain level of 4 on a scale of 0 to 10 is moderate but not life-threatening. It should be managed, but it is less urgent compared to other assessment findings.
H. The child is using accessory muscles for respiration and is experiencing dyspnea while at rest, which suggests worsening respiratory distress. This is crucial to report as it reflects the severity of the pneumonia and may need adjustments in the treatment plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Puberty might be considered delayed if there are no scrotal changes by the age of 11 years, as testicular enlargement is one of the earliest signs of puberty in boys.
B. Growth spurts typically occur early in puberty, not towards the end.
C. Changes in voice occur later in puberty, not at the beginning.
D. Gynecomastia (breast tissue development) commonly occurs during early puberty rather than late puberty and is usually temporary.
Correct Answer is B
Explanation
A. Encouraging deep breathing is important for preventing pulmonary complications but is not the priority in managing a vaso-occlusive crisis.
B. Maintaining hydration through intravenous fluids is the priority as it helps to reduce blood viscosity and prevent further sickling of cells, which is critical in managing a vaso-occlusive crisis.
C. Active range-of-motion exercises are important but are not a priority during an acute vaso-occlusive crisis.
D. A protein-rich diet supports overall health but is not immediately relevant to the acute management of a vaso-occlusive crisis.
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