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 D
Explanation
D. If the tympanostomy tubes fall out, the parent should contact the healthcare clinic or the healthcare provider who performed the procedure. They can provide guidance on whether the child needs to be seen for an evaluation and potential replacement of the tubes. Reporting the situation allows for appropriate follow-up and management by the healthcare team.
A. Tympanostomy tubes are small tubes inserted into the eardrums to help drain fluid from the middle ear and prevent recurrent ear infections. While they are designed to stay in place for a certain period, it is possible for them to fall out prematurely.
B. It's important for the parent to seek medical advice if the tubes fall out but it may not always require an immediate visit to the emergency department. However, if the child experiences severe pain, bleeding, or signs of infection after the tubes fall out, seeking urgent medical attention may be warranted.
C. Only a healthcare provider should insert or reinsert tympanostomy tubes. Attempting to reinsert the tubes at home without proper training and equipment could cause injury or damage to the ear.
Correct Answer is A
Explanation
A. This is a common postictal manifestation after a generalized tonic-clonic seizure. Following the intense muscle activity and convulsions during the seizure, the child may experience exhaustion and feel sleepy. The postictal state often involves a period of drowsiness or even brief loss of consciousness.
B. Restlessness is less likely to be observed immediately after a generalized tonic-clonic seizure. Instead, the child is more likely to exhibit fatigue and lethargy as the body recovers from the seizure activity.
C. Anxiety may occur during or immediately after the seizure due to the sudden and frightening nature of the event. However, in the postictal period, anxiety typically diminishes as the child becomes more oriented and aware of their surroundings.
D. Nausea is not a typical postictal manifestation after a generalized tonic-clonic seizure. While some individuals may experience nausea or vomiting during the seizure (ictal phase), it is less common in the postictal period.
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