A nurse is caring for a school-age child.
Which of the following assessment findings should the nurse report to the provider?
Select the 4 findings that the nurse should report to the provider.
Oral intake
Blood pressure
Temperature
Oxygenation
Gastrointestinal status
Sputum
Pain
Respiratory effort
Correct Answer : B,D,E,H
A. While the child’s oral intake is reduced, it is not as immediately critical as the other findings. However, it should still be monitored and managed.
B. The child’s blood pressure has dropped to 88/48 mm Hg on Day 3, which is significantly lower than the initial value and may indicate hypotension. This could be a sign of worsening condition or dehydration and needs to be reported for further evaluation and intervention.
C. The temperature of 38.1° C (100.6° F) on Day 3 indicates a fever but is lower than the initial admission temperature. It is important but not as critical as the other findings in this scenario.
D. The oxygen saturation has decreased to 88% on room air, which is below the normal range and indicates hypoxemia. This is critical in a patient with pneumonia and cystic fibrosis, and it requires immediate attention to manage respiratory function and oxygenation.
E. The child has passed three large, frothy, foul-smelling stools, which could be indicative of a gastrointestinal complication, possibly related to cystic fibrosis. This change in bowel habits should be reported as it may impact the child’s overall condition and treatment plan.
F. The sputum is thick, yellow, and blood-streaked, which is consistent with the condition but does not require immediate reporting unless there is a significant change in color or consistency.
G. The reported pain level of 4 on a scale of 0 to 10 is moderate but not life-threatening. It should be managed, but it is less urgent compared to other assessment findings.
H. The child is using accessory muscles for respiration and is experiencing dyspnea while at rest, which suggests worsening respiratory distress. This is crucial to report as it reflects the severity of the pneumonia and may need adjustments in the treatment plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Cromolyn sodium is a preventive medication and should be taken regularly as prescribed, not at the first sign of breathing difficulty.
B. Avoiding triggers that cause an asthma attack is crucial in asthma management and helps in preventing exacerbations.
C. Exercise can be managed in asthma with appropriate medication; it is not necessary to stop activities like basketball. Swimming may be less likely to trigger asthma symptoms but is not a blanket solution.
D. The peak expiratory flow meter should be used regularly, often daily, to monitor asthma control, not just once per week.
Correct Answer is D
Explanation
A. Switching formula is not the first intervention, as projectile vomiting in an infant can indicate a more serious condition such as pyloric stenosis, which requires medical evaluation.
B. Oral rehydration solution may be needed if the infant is dehydrated, but the cause of vomiting must be assessed first.
C. While burping can reduce gas and discomfort, it is unlikely to resolve projectile vomiting, which may be due to a more serious underlying condition.
D. Bringing the baby to the clinic is the most appropriate action, as projectile vomiting can be a sign of pyloric stenosis or another serious condition that requires prompt medical attention.
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