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. While fluid replacement is important, in a toxic-appearing child, oral fluids may not be safe or adequate due to potential dehydration and risk of worsening condition.
B. Administering antibiotics is the priority action because the child shows signs of potential serious infection, and timely antibiotic treatment is crucial in young infants who may quickly deteriorate.
C. Obtaining a specimen for a complete blood count is necessary for diagnosing infection but is not as urgent as administering antibiotics.
D. While obtaining a urinalysis may help identify a urinary tract infection, it is not the immediate priority compared to starting antibiotic therapy.
Correct Answer is B
Explanation
A. While abdominal surgery may be needed in some cases of intussusception, non-surgical interventions are often attempted first.
B. An enema with air infusion (often a contrast enema) can be used to treat intussusception by helping to unfold the intestine, making it a commonly discussed procedure.
C. An ano-rectal pull-through procedure is not related to intussusception and is usually indicated for conditions like Hirschsprung's disease.
D. A colostomy may be necessary in cases of bowel necrosis or perforation but is not the first-line treatment for intussusception.
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