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","D","E"]
Explanation
A. Nighttime symptoms occurring twice a month is more characteristic of intermittent asthma rather than mild persistent asthma, which might present with nighttime symptoms more frequently.
B. In mild persistent asthma, the peak expiratory flow (PEF) is typically greater than or equal to 80% of the predicted value, indicating relatively good control of asthma symptoms.
C. Continuous symptoms throughout the day are not typical for mild persistent asthma; symptoms usually occur intermittently.
D. Minor limitations with normal activity are expected in mild persistent asthma, as the condition can cause some restrictions in daily activities but not severe impairments.
E. Daytime symptoms occur more than twice a week. This is a key feature of mild persistent asthma. Intermittent asthma = ≤2 days/week. Daily symptoms would indicate moderate persistent.
Correct Answer is A
Explanation
A. Sitting the child upright and forward while applying pressure to the sides of the nose is the correct approach to managing a nosebleed. This position prevents blood from flowing down the throat and helps stop the bleeding by applying direct pressure.
B. Turning the child's head to the side and pressing on the nasal ridge is incorrect because it does not effectively control the bleeding and may cause blood to flow into the throat.
C. Lying the child in bed and pressing on the forehead is not effective in controlling a nosebleed.
D. Lying flat and applying pressure to the cheeks does not address the source of the bleeding and may worsen the situation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.