Exhibits
Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.
WBC count
Hemoglobin
Upper respiratory infection
Breath sounds
Oxygen saturation
Retractions
Respiratory rate
Skin assessment
Correct Answer : A,B,D,E,F,H
A. The WBC count is elevated at 15,000/mm³, which indicates leukocytosis. In a child with leukemia, this could suggest a potential relapse or an ongoing infection, which requires prompt evaluation by the provider.
B. The hemoglobin level is at the lower limit of normal (10 g/dL). This can indicate anemia, which is significant in a child with a history of leukemia and may require further investigation or intervention.
C. While the ongoing upper respiratory infection is concerning, it is less urgent than the other findings. The nurse should monitor this but may not need to report it as a critical finding compared to the child's acute symptoms.
D. The presence of clear breath sounds is expected; however, they should be reported in the context of the child's respiratory distress and the associated findings.
E. An oxygen saturation of 92% on room air is below the normal range and indicates hypoxia. This is a critical finding that requires immediate attention from the provider.
F. Subcostal retractions indicate increased work of breathing and respiratory distress, which is an urgent assessment finding that must be communicated to the provider.
G. While the respiratory rate is relevant, the specific number was not provided, and unless it indicates significant distress or abnormality, it may not be a priority report compared to the other findings.
H. The presence of petechiae is concerning, especially in a child with a history of leukemia. This could indicate thrombocytopenia or another hematological issue, which requires further evaluation by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Educating the family about antibiotics is important but not the immediate priority for symptom management.
B. Administering analgesic medication addresses the child's pain and discomfort, which is a priority in acute otitis media.
C. Applying an ice pack can provide some comfort but does not directly address the child's pain as effectively as medication.
D. Providing diversional activities may help occupy the child but is not a direct intervention for the pain associated with acute otitis media.
Correct Answer is ["A","B","C","E"]
Explanation
A. Encouraging frequent fluid intake helps to dilute the urine and promotes urination, which can help flush out bacteria.
B. Frequent voiding is essential to reduce the risk of bacterial growth in the bladder and to alleviate symptoms.
C. Wiping from front to back is important in preventing the spread of bacteria from the rectal area to the urethra, thereby reducing the risk of UTIs.
D. Wearing nylon underwear may trap moisture and create an environment conducive to bacterial growth; cotton underwear is preferred.
E. Completing the course of antibiotics is crucial for fully eradicating the infection and preventing recurrence.
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