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. Bagels with cream cheese and lox are not recommended as lox may carry a risk of contamination.
B. A vanilla milkshake made with pasteurized milk is safe for a neutropenic diet as pasteurization kills harmful bacteria.
C. Ham and cheese sandwiches may not be safe unless the ham is fully cooked, as deli meats can harbor bacteria.
D. Sushi is not appropriate for a neutropenic diet due to the risk of raw fish and potential bacteria.
Correct Answer is ["A","B","C","D","E","F"]
Explanation
A. Avoiding bubble baths is important as they can irritate the urethra and exacerbate UTIs.
B. Wiping the perineal area from front to back is essential to prevent bacteria from the rectal area from entering the urinary tract.
C. Completing the course of prescribed antibiotics is crucial to fully eradicate the infection and prevent recurrence.
D. Encouraging frequent voiding helps to flush out bacteria from the urinary tract and prevent infection.
E. Wearing cotton underwear helps keep the area dry and reduce the risk of bacterial growth.
F. Encouraging frequent fluid intake aids in hydration and helps dilute the urine, reducing irritation and promoting flushing of bacteria.
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