A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately?
Blood glucose 140 mg/dL
Serum sodium 156 mEq/L
RBC 3.2 million/ul
Oxygen saturation 85%
The Correct Answer is D
D. An oxygen saturation level of 85% is significantly below the normal range and indicates hypoxemia (low blood oxygen levels). This finding is concerning, especially in a child with cystic fibrosis, which can lead to respiratory complications such as airway obstruction, infection, or mucus plugging.
A. A blood glucose level of 140 mg/dL is within the normal range for children, so this finding would not typically require immediate reporting to the provider.
B. A serum sodium level of 156 mEq/L is significantly elevated and above the normal range. However, hypoxia is the priority.
C. A red blood cell (RBC) count of 3.2 million/µL falls within the normal range for children, so this finding would not typically require immediate reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Frequent swallowing is a common finding after a tonsillectomy due to postoperative throat discomfort and the sensation of having a foreign object in the throat (such as blood clots or mucus).
B. Reports of thirst may indicate dehydration, which can occur after surgery, especially if the child is not drinking enough fluids due to pain or discomfort. While dehydration can be a concern after a tonsillectomy, it is not a specific sign of hemorrhage.
C. Pain is common after a tonsillectomy and can be expected in the postoperative period. While increased pain may be present if hemorrhage occurs, it is not a specific sign of hemorrhage on its own.
D.Mouth breathing does not directly indicate bleeding and is more related to discomfort or difficulty breathing through the nose, especially if the child is experiencing throat pain. It is not a typical sign of hemorrhage.
Correct Answer is C
Explanation
C. This is characteristic of Kernig's sign. Kernig's sign is elicited when the thigh is flexed at the hip and then attempts to extend the leg at the knee are met with resistance or pain due to inflammation of the meninges.
A. Petechial and purpuric rashes are associated with meningococcal meningitis, not specifically with Kernig's sign. These rashes result from bleeding into the skin and are a characteristic feature of meningococcal sepsis. However, they are not directly related to Kernig's sign.
B. This observation describes Brudzinski's sign, not Kernig's sign. Brudzinski's sign occurs when passive flexion of the neck causes involuntary flexion of the hips and knees due to meningeal irritation.
D. Muscle and joint pain can be symptoms of meningitis, but they are not specific to Kernig's sign. Kernig's sign specifically refers to resistance or pain experienced when attempting to extend the leg at the knee.
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