A nurse is caring for a school-age child who has leukemia.
Which of the following assessment findings should the nurse report to the provider?
Select the 6 findings that should be reported to the provider.
WBC count
Hemoglobin
Upper respiratory infection
Breath sounds
Oxygen saturation
Retractions
Respiratory rate
Skin assessment
Correct Answer : A,B,D,E,F,H
A. The WBC count is elevated at 15,000/mm³, which indicates leukocytosis. In a child with leukemia, this could suggest a potential relapse or an ongoing infection, which requires prompt evaluation by the provider.
B. The hemoglobin level is at the lower limit of normal (10 g/dL). This can indicate anemia, which is significant in a child with a history of leukemia and may require further investigation or intervention.
C. While the ongoing upper respiratory infection is concerning, it is less urgent than the other findings. The nurse should monitor this but may not need to report it as a critical finding compared to the child's acute symptoms.
D. The presence of clear breath sounds is expected; however, they should be reported in the context of the child's respiratory distress and the associated findings.
E. An oxygen saturation of 92% on room air is below the normal range and indicates hypoxia. This is a critical finding that requires immediate attention from the provider.
F. Subcostal retractions indicate increased work of breathing and respiratory distress, which is an urgent assessment finding that must be communicated to the provider.
G. While the respiratory rate is relevant, the specific number was not provided, and unless it indicates significant distress or abnormality, it may not be a priority report compared to the other findings.
H. The presence of petechiae is concerning, especially in a child with a history of leukemia. This could indicate thrombocytopenia or another hematological issue, which requires further evaluation by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Passing flatus every 30 minutes indicates bowel activity and suggests that the child may be able to resume oral intake.
B. Absent bowel sounds indicate a lack of gastrointestinal function, which supports the continuation of NPO status until bowel function returns.
C. An increase in abdominal girth, even by 1 cm, can be concerning postoperatively and may indicate fluid retention or other issues, warranting further assessment.
D. Pain at the operative site is expected post-surgery, but it does not directly relate to the child’s ability to resume oral intake.
Correct Answer is B
Explanation
A. Acetaminophen can be given every 4 to 6 hours, but every 2 hours is too frequent and indicates a need for further teaching.
B. The maximum daily dose for a child should be based on their weight and typically should not exceed 75 mg/kg/day; stating 4000 mg is too high for a child, indicating a misunderstanding of dosing.
C. Administering acetaminophen rectally is appropriate if the child cannot take it orally, particularly during vomiting episodes.
D. Notifying the provider about jaundice is critical, as it may indicate liver dysfunction, which is important when using acetaminophen.
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