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. Switching to a different formula may not address the underlying issue and could lead to further complications.
B. Bringing the baby to the clinic is essential as projectile vomiting in an infant can indicate a serious condition such as pyloric stenosis that requires evaluation and intervention.
C. Giving oral rehydration solutions is not appropriate before assessing the infant's condition, especially if there’s a possibility of a serious underlying issue.
D. While burping is generally recommended, it is not the solution to the problem of projectile vomiting and does not address the need for urgent assessment.
Correct Answer is A
Explanation
A. The primary treatment for congenital aganglionic megacolon (Hirschsprung's disease) is surgical intervention to remove the affected segment of the bowel, allowing for normal bowel function and preventing complications such as bowel obstruction.
B. Oral iron preparations would not address the underlying condition of Hirschsprung's disease, which is related to the lack of nerve cells in the bowel.
C. While counseling may be beneficial for the caregivers regarding the diagnosis and care, it is not the primary treatment for Hirschsprung's disease.
D. While enemas may be used temporarily to relieve constipation, they are not a definitive treatment for the disease, which requires surgical correction.
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