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. Hypotension is not typically associated with coarctation of the aorta; it more often leads to hypertension in the upper body.
B. Unequal pulses in the upper and lower extremities are a classic sign of coarctation of the aorta, as the obstruction typically affects blood flow to the lower body.
C. Excessive crying is not a specific indicator of coarctation of the aorta and can occur due to various reasons.
D. A diastolic murmur is not a primary indicator of coarctation of the aorta; it is more associated with other cardiac conditions.
Correct Answer is D
Explanation
A. Collecting all urine may be relevant in certain conditions, such as kidney function monitoring, but it is not specific to Wilms' tumor management.
B. Restrictions on venipuncture or blood pressure in a specific arm are relevant for conditions like lymphedema or post-mastectomy, not Wilms' tumor.
C. Contact precautions are necessary for infectious diseases, not applicable to Wilms' tumor.
D. Wilms' tumor is a renal tumor, and palpating the abdomen could potentially cause the tumor to rupture and spread malignant cells. Therefore, it is critical to avoid any abdominal palpation in these patients.
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