Leukemia in a School-Age Child

A nurse is caring for a 10-year-old male child in the pediatric unit who has leukemia and was brought in for an ongoing upper respiratory infection.

Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.

Choice A rationale

Crepitus, or subcutaneous emphysema, is the presence of air in the subcutaneous tissues, often around the chest tube insertion site. While it indicates air leakage from the pleural space, often a minor leak, it is a common finding and does not always warrant immediate notification unless extensive or rapidly worsening.

Choice B rationale

Bubbling of water in the water seal chamber with exhalation in a client with a pneumothorax indicates that air is still escaping from the pleural space, which is an expected finding as the lung re-expands. Continuous or excessive bubbling may indicate a persistent air leak, but intermittent bubbling with exhalation is normal during pneumothorax resolution.

Choice C rationale

Movement of the trachea toward the unaffected side is a cardinal sign of a tension pneumothorax. This life-threatening condition occurs when air accumulates in the pleural space under positive pressure, compressing the lung, displacing the mediastinum, and compromising venous return to the heart. This requires immediate medical intervention.

Choice D rationale

Visible eyelets indicate that a portion of the chest tube is outside the pleural space, which can compromise the tube's effectiveness in draining air or fluid and create a pathway for infection. While this finding is concerning and requires assessment, it is not as immediately life-threatening as a tracheal shift indicative of tension pneumothorax.

Choice A rationale

Discussing insurance coverage is beyond the nurse's scope of practice and does not address the immediate safety concern related to the elevated INR. The nurse's primary responsibility is patient safety and education regarding potential health risks, not financial implications. The client's autonomy in making healthcare decisions is paramount.

Choice B rationale

A client cannot be legally detained in a healthcare facility against their will, assuming they are of sound mind. Requiring a signed Against Medical Advice (AMA) form is a documentation process, not a prerequisite for discharge. Detaining a competent client constitutes false imprisonment, violating their civil liberties.

Choice C rationale

Asking security to guard the room is a restrictive action that infringes upon the client's autonomy and right to leave. This approach is coercive and may escalate the situation, potentially leading to a legal and ethical dilemma. It does not prioritize patient education or safety through explanation.

Choice D rationale

Explaining the risks associated with leaving against medical advice, especially with an elevated INR, is crucial for informed decision-making. An INR of 3.5 indicates increased bleeding risk (normal range 0.8-1.2 or 2.0-3.0 for therapeutic anticoagulation). Providing this scientific information allows the client to understand potential adverse physiological events.