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. Tugging or pulling on the affected ear lobe is a classic sign of otitis media in infants. The discomfort or pain caused by inflammation and pressure in the middle ear may lead the infant to tug or rub the affected ear in an attempt to alleviate discomfort.
A. Bluish-green discharge from the ear canal is not a typical finding in otitis media. Otitis media is characterized by inflammation and fluid accumulation in the middle ear, which may not result in discharge unless there is a secondary bacterial infection or perforation of the eardrum.
B. An increase in appetite is not a typical finding in otitis media. In fact, many children with otitis media may experience a decrease in appetite due to discomfort, pain, and difficulty swallowing or chewing.
C. Erythema (redness) and edema (swelling) of the affected auricle (outer ear) are not typically associated with otitis media. Otitis media primarily affects the middle ear, where inflammation and fluid accumulation occur behind the eardrum.
Correct Answer is C
Explanation
C. Clubbing, characterized by bulbous enlargement of the fingertips and nail bed, is a result of chronic hypoxia in tetralogy of Fallot. In tetralogy of Fallot, there is a right-to-left shunting of blood due to the presence of a ventricular septal defect, overriding aorta, pulmonary stenosis, and right ventricular hypertrophy. This leads to reduced oxygenation of blood and chronic hypoxia, which can result in clubbing of the fingertips over time.
A This option is not the primary explanation for clubbing in tetralogy of Fallot. While decreased cardiac output may contribute to some manifestations of the condition, clubbing specifically results from chronic hypoxia rather than decreased cardiac output alone.
B Clubbing is not directly caused by a left-to-right shunting of blood. Instead, it is associated with chronic hypoxia, which can occur due to right-to-left shunting of blood in tetralogy of Fallot.
D Congestive heart failure may occur in individuals with tetralogy of Fallot but it is not the primary cause of clubbing. Clubbing in tetralogy of Fallot is primarily attributed to chronic hypoxia rather than heart failure alone.
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