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 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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
