A child diagnosed with strep throat 3 days ago enters the clinic crying hysterically. The parent tells the practical nurse (PN) that the child screams in pain even with a light touch. The child is short of breath and anxious. Which manifestations warrant immediate intervention by the PN?
Slightly raised rash with ragged edges.
Red, hot, and swollen joints.
Heart rate 110 beats/minute.
Pulse oximetry of 88% O2 saturation.
Correct Answer : B,D
A. A slightly raised rash with ragged edges might indicate a mild skin condition but isn't typically an immediate concern for intervention in this scenario.
B. Red, hot, and swollen joints could indicate a serious condition like septic arthritis and would require immediate attention.
C. While an elevated heart rate can be a concern, it might be expected in a distressed child and might not be as urgent as other symptoms in this case.
D. A pulse oximetry reading of 88% O2 saturation indicates a significant decrease in oxygen levels and requires immediate intervention to ensure adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Oriented x 3. - The client must recall the time, day, date, location, and reason for being there to be considered oriented x 3. As the client can only remember his name and location, it does not fulfill the criteria for oriented x 3.
B. Oriented x 1. - This is inaccurate as the patient is oriented in two aspects: person and place.
C. Oriented x 2. - The client recalls their name and place, hence is oriented in two aspects. This is therefore accurate.
D. Oriented x 4. - This would require the client to recall all four aspects of orientation (time, day, date, location, and reason for being there), which the client did not demonstrate in this scenario.
Correct Answer is B
Explanation
A. Sodium level of 130 mEq/L is slightly below the lower limit of the reference range but might not have as immediate an impact on safety as a critically low hemoglobin level.
B. Hemoglobin of 8.9 grams/dL is significantly below the normal range and indicates a substantial drop in red blood cells, which can lead to impaired oxygen transport and potentially severe postoperative complications like inadequate tissue perfusion and oxygenation.
C. Potassium level of 3.4 mEq/L is slightly below the lower limit of the reference range but might not pose an immediate threat compared to a critically low hemoglobin level.
D. Blood urea nitrogen (BUN) of 20 mg/dL is at the upper limit of the reference range but might not have an immediate implication for client safety compared to a critically low hemoglobin level.
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