Exhibit 1. Diagnostic Results.
HbA1c 8.5%. Exhibit 2. Hgb 13.5 mg/dL. Hct 39%. WBC count 9,600/mm3.
Exhibit 3. A nurse is reviewing the medical record of a school-age child who has cystic fibrosis.
Which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client.
There are three tabs that contain separate categories of data.)
Heart rate.
WBC count.
HbA1c.
Oxygen saturation.
The Correct Answer is D
Choice A rationale:
The nurse does not need to report the heart rate as it falls within the normal range for a school-age child, which is typically between 70-100 beats per minute.
Choice B rationale:
The WBC count is 9,600/mm3, which is within the normal range for a school-age child (4,500 to 13,500/mm3) Therefore, this finding does not warrant reporting to the provider.
Choice C rationale:
HbA1c level is 8.5%, indicating poor blood sugar control. However, this finding is related to the child's cystic fibrosis and not an immediate concern. The nurse should address this issue but does not need to urgently report it to the provider.
Choice D rationale:
Oxygen saturation is 95%, which is within the normal range (typically 95-100%) However, for a child with cystic fibrosis who may have respiratory issues, a lower oxygen saturation level might be concerning. Therefore, the nurse should report this finding to the provider for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Checking oxygen saturation every 4 hours is a monitoring parameter for patients with respiratory issues but is not the priority in a child with acute epiglottitis. Airway management and infection control are more critical in this situation.
Choice B rationale:
Obtaining a throat culture is important to confirm the diagnosis of epiglottitis. However, initiating isolation precautions and ensuring the child's airway is secure take precedence in the immediate care of a child with acute epiglottitis.
Choice C rationale:
Assisting the child into a supine position is contraindicated in acute epiglottitis. This position can further compromise the airway by obstructing it. The child should be allowed to sit in a position of comfort, usually sitting upright and leaning slightly forward.
Choice D rationale:
Initiating droplet isolation precautions is crucial when dealing with a suspected or confirmed case of epiglottitis. Epiglottitis is highly contagious and is transmitted via respiratory droplets. Isolation precautions help prevent the spread of the infection to others.
Correct Answer is B
Explanation
Choice A rationale:
Moisten the mucosa with lemon glycerin swabs is not recommended because lemon glycerin swabs can be acidic and may irritate the oral ulcers further. It's important to avoid irritating substances in the oral cavity to promote healing.
Choice B rationale:
Cleaning the gums with saline-soaked gauze is a gentle and non-irritating method to maintain oral hygiene for a toddler with oral ulcers. Saline solution helps keep the oral cavity clean and reduces the risk of infection without causing further irritation.
Choice C rationale:
Administering oral viscous lidocaine is not recommended for routine use in managing oral ulcers in children. Lidocaine can be absorbed systemically and lead to toxicity, especially in young children. It should only be used under the guidance of a healthcare provider and in specific circumstances where the benefits outweigh the risks.
Choice D rationale:
Scheduling routine oral care every 8 hours is important, but the method of oral care is equally crucial. Using gentle methods like saline-soaked gauze to clean the gums ensures proper hygiene without causing discomfort to the child.
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