A nurse on a pediatric unit is preparing to admit a preschooler after receiving a transfer report from a nurse in the emergency department. Which of the following findings should the nurse report to the provider immediately?
The child has not had a bowel movement for 5 days.
The child is crying and clinging to the guardian.
The child has a temperature of 38.8°C (101.9°F) tympanic.
The insertion site of the central line catheter is erythematous with a scant amount of purulent drainage.
The Correct Answer is D
Choice A reason: The child has acute lymphoblastic leukemia (ALL) and is receiving chemotherapy and steroids, which can cause constipation. The nurse should monitor the child's bowel function and provide interventions such as fluids, fiber, and laxatives as prescribed, but this is not an urgent finding.
Choice B reason: The child is in the induction phase of treatment for ALL, which can be stressful and frightening for the child and the family. The child's crying and clinging behavior indicates anxiety and fear, which are normal reactions. The nurse should provide emotional support and education to the child and the guardian, but this is not an urgent finding.
Choice C reason: The child has a fever, which is a common side effect of chemotherapy and steroids. The nurse should assess the child for other signs of infection, administer antipyretics as prescribed, and monitor the child's vital signs, but this is not an urgent finding.
Choice D reason: The child has a double-lumen central line catheter in the left chest wall, which is a potential source of infection. The erythema and purulent drainage at the insertion site indicate that the child has a local infection, which can spread to the bloodstream and cause sepsis. This is a life-threatening complication that requires immediate attention and treatment. The nurse should report this finding to the provider, obtain blood cultures, and administer antibiotics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The onset of low blood glucose, or hypoglycemia, usually occurs rapidly and can be triggered by skipping meals, exercising too much, or taking too much insulin. The nurse should teach the parents to recognize the signs and symptoms of hypoglycemia and how to treat it promptly.
Choice B reason: Feeling shaky is one of the common signs of low blood glucose, along with hunger, sweating, dizziness, confusion, and irritability. The nurse should teach the parents to check the child's blood glucose level and give him a fast-acting carbohydrate, such as juice, candy, or glucose tablets, if it is below 70 mg/dL.
Choice C reason: Sweating can occur with low blood glucose, not high blood glucose, or hyperglycemia. Hyperglycemia can cause symptoms such as thirst, frequent urination, dry mouth, blurred vision, and fatigue. The nurse should teach the parents to monitor the child's blood glucose level regularly and adjust his insulin dose, diet, and exercise accordingly.
Choice D reason: Nausea and vomiting can occur with high blood glucose, especially if it leads to diabetic ketoacidosis, a serious complication of diabetes. Diabetic ketoacidosis can also cause abdominal pain, fruity breath, rapid breathing, and coma. The nurse should teach the parents to seek emergency medical attention if the child has these symptoms.
Correct Answer is A
Explanation
Choice A reason: This is a contraindication for the MMR immunization, which is a live attenuated vaccine. A child who has a congenital immunodeficiency may not be able to mount an adequate immune response to the vaccine and may be at risk of developing the diseases from the vaccine.
Choice B reason: This is not a contraindication for the MMR immunization. A mild fever after a previous immunization is not a sign of an allergic reaction or a serious adverse effect. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.
Choice C reason: This is not a contraindication for the MMR immunization. Taking antibiotics for otitis media does not interfere with the effectiveness or safety of the vaccine. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.
Choice D reason: This is not a contraindication for the MMR immunization. A mild cough and a low-grade fever are not signs of a moderate or severe illness that would prevent the child from receiving the vaccine. The child can still receive the MMR immunization as long as they do not have any other contraindications.
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