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A pediatric nurse is assisting with the care of a school-age child who has leukemia.

Exhibits
Which of the following data collection findings should the nurse report to the provider? Select the 5 findings that should be reported to the provider.

Blood pressure

Skin assessment

Breath sounds

Oxygen saturation

WBC count

Retractions

Respiratory rate

Hemoglobin

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Skin color: While skin color can show signs of reactions, it is a secondary measure. Temperature changes can be more immediately significant in assessing transfusion reactions.

B. Temperature: Temperature is the priority because a fever can indicate an infection or may develop as a sign of a transfusion reaction. Monitoring baseline temperature helps quickly identify febrile reactions to the transfusion.

C. Hemoglobin level: Although important to verify, the hemoglobin level is part of the overall assessment but does not directly predict or prevent transfusion reactions.

D. Fluid intake: Fluid intake is monitored for fluid overload risk but is not as immediate in the prevention of transfusion reactions.

A. The patient should increase intake of fluids. B. The patient should increase intake of fresh fruits. C. The patient should decrease intake of red meat. D. The patient should avoid alcoholic beverages.

Correct Answer is A

Explanation

A. The patient should increase intake of fluids. Increased fluid intake helps flush excess calcium from the kidneys, which is vital for patients with hypercalcemia, a common complication of multiple myeloma.

B. The patient should increase intake of fresh fruits. Fresh fruits can be healthy but do not directly reduce hypercalcemia risk. Fluid intake is more critical in preventing calcium build up.

C. The patient should decrease intake of red meat. While reducing red meat can be beneficial for overall health, it does not directly address hypercalcemia.

D. The patient should avoid alcoholic beverages. Avoiding alcohol is generally beneficial, but it is not specifically related to managing hypercalcemia in multiple myeloma.

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A pediatric nurse is assisting with the care of a school-age child who has leukemia. Exhibits Which of the following data collection findings should the nurse report to the provider? Select the 5 findings that should be reported to the provider.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who is to receive a blood transfusion. Which of the following data is the nurse's priority before the transfusion begins?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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A pediatric nurse is assisting with the care of a school-age child who has leukemia.

Exhibits
Which of the following data collection findings should the nurse report to the provider? Select the 5 findings that should be reported to the provider.