A pediatric nurse is assisting with the care of a school-age child who has leukemia.
Blood pressure
Skin assessment
Breath sounds
Oxygen saturation
WBC count
Retractions
Respiratory rate
Hemoglobin
Correct Answer : B,C,D,F,G
A. Blood pressure: The blood pressure is within normal limits and does not indicate an acute issue in this context.
B. Skin assessment: The presence of pallor and bruising indicates potential anemia and thrombocytopenia, common in leukemia patients but concerning signs that need to be monitored.
C. Breath sounds: Rhonchi in the upper lobes suggest respiratory congestion or infection, which is dangerous in an immunocompromised child.
D. Oxygen saturation: A drop in oxygen saturation to 90% indicates impaired oxygenation, which could signify respiratory distress or worsening infection.
E. WBC count: Although WBC count is within the low-normal range, it does not independently indicate an immediate change in the child’s condition.
F. Retractions: Subcostal retractions indicate respiratory distress, which is critical to report as it could escalate quickly in a child.
G. Respiratory rate: The increased respiratory rate (from 22 to 30/min) reflects respiratory distress and may worsen if the infection progresses.
H. Hemoglobin: While low, the hemoglobin is not acutely life-threatening in this case and would not necessarily prompt urgent intervention without other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Aplastic anemia results from decreased bone marrow production of RBCs." Aplastic anemia is characterized by the failure of bone marrow to produce adequate red blood cells (RBCs), white blood cells, and platelets. This results in pancytopenia, which increases the risk of infections, anemia, and bleeding.
B. "Aplastic anemia is directly related to impaired liver function." Aplastic anemia is not related to liver function; it originates from the bone marrow’s inability to produce sufficient blood cells.
C. "Aplastic anemia is associated with the decreased intake of iron." Aplastic anemia is not caused by iron deficiency; it is primarily due to bone marrow failure. Iron deficiency anemia, on the other hand, results from a lack of iron intake or absorption.
D. "Aplastic anemia results in an increased rate of RBC destruction." Increased RBC destruction is characteristic of hemolytic anemia, not aplastic anemia.
Correct Answer is C
Explanation
A. Intense abdominal pain: While abdominal pain may occur in some conditions related to anemia, it is not a typical finding in anemia due to blood loss.
B. Respiratory depression: Respiratory depression is not commonly associated with anemia and would more likely indicate issues with central nervous system depression or drug side effects.
C. Dyspnea on exertion: Dyspnea on exertion is common in clients with anemia because of the decreased oxygen-carrying capacity of the blood, leading to tissue hypoxia. Anemia results in decreased hemoglobin levels, reducing the body’s ability to deliver adequate oxygen, particularly during physical activity.
D. Bradycardia: Anemia typically causes tachycardia (increased heart rate) rather than bradycardia, as the body compensates for low oxygen levels by increasing cardiac output.
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