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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.

A.

Blood pressure

B.

Skin assessment

C.

Breath sounds

D.

Oxygen saturation

E.

WBC count

F.

Retractions

G.

Respiratory rate

H.

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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Related Questions

Correct Answer is D

Explanation

A. Explain the procedure to the patient’s family: While helpful, this is not as crucial as ensuring patient comfort and pain management during the procedure itself.

B. Observe the patient for bleeding: Observing for bleeding is important post-procedure rather than beforehand.

C. Drape the biopsy site: Draping is part of the procedure setup, but pain management is more critical for patient preparation.

D. Administer an analgesic to the patient: Administering an analgesic is essential to manage pain and discomfort during a bone marrow biopsy. This ensures the patient is as comfortable as possible.

Correct Answer is C

Explanation

A. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. A nebulizer is typically not the initial intervention for mild post-operative pain or mild respiratory discomfort due to pain with inspiration.

B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. While heat or cold therapy can help with pain, opioid pain management with encouragement to perform deep breathing exercises is more effective for post-splenectomy patients.

C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. Pain management combined with encouraging deep breathing, coughing, and early ambulation helps prevent post-operative complications like atelectasis and pneumonia, which are common after abdominal surgeries.

D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential. This intervention might be necessary if there were signs of infection or other complications, but mild pain with inspiration on the first day post-op does not typically warrant imaging or labs.

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