A nurse is caring for a school-age child in the hospital.
Which of the following assessment findings should the nurse report to the provider? (Select all that apply)
Oxygen saturation: 88% on room air
Heart rate: 128/min
Child reports chest discomfort as 4 on a scale of 0 to 10
WBC: 15,000/mm³
Passed three large, frothy, foul-smelling stools
Correct Answer : A,B,E
Choice A rationale:
Oxygen saturation of 88% on room air is significantly below the normal range (95-100%) and indicates hypoxemia. This finding should be reported to the provider as it may require supplemental oxygen or other interventions.
Choice B rationale:
A heart rate of 128/min is elevated for a school-age child and may indicate increased work of breathing, fever, or other underlying issues. This finding should be reported to the provider for further evaluation.
Choice C rationale:
While the child reporting chest discomfort as 4 on a scale of 0 to 10 is important, it is not as critical as the other findings. The provider should be aware of the discomfort, but it may not require immediate intervention.
Choice D rationale:
An elevated WBC count of 15,000/mm³ indicates an infection, which is consistent with the diagnosis of bilateral pneumonia. While this is important information, it is expected in the context of the current diagnosis and may not require immediate reporting.
Choice E rationale:
Passing three large, frothy, foul-smelling stools is significant in a child with cystic fibrosis as it may indicate malabsorption or other gastrointestinal issues. This finding should be reported to the provider for further evaluation and potential adjustment of the treatment plan.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.6"]
Explanation
Step 1: Convert the child’s weight from pounds to kilograms. 66 lb ÷ 2.2 = 30 kg
Step 2: Calculate the total daily dose of digoxin. 12 mcg/kg/day × 30 kg = 360 mcg/day
Step 3: Divide the total daily dose by 2 to get the dose for every 12 hours. 360 mcg/day ÷ 2 = 180 mcg/dose
Step 4: Convert mcg to mg. 180 mcg = 0.18 mg Step 5: Calculate the volume to administer per dose using the concentration of the elixir. 0.18 mg ÷ 0.05 mg/mL = 3.6 mL
Final calculated answer: 3.6 mL per dose.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
While discipline is an important aspect of parenting, the nurse’s response should focus on normalizing the child’s behavior and providing reassurance to the parent. Discussing discipline methods may not address the parent’s immediate concern about temper tantrums.
Choice B rationale
Suggesting that some children have more difficult personalities and recommending parenting books may not provide the immediate reassurance and understanding the parent needs. It is important to normalize the child’s behavior and explain that temper tantrums are a normal part of development.
Choice C rationale
Toddlers are beginning to develop a sense of autonomy and independence, which can lead to temper tantrums as they assert their desires and preferences. Explaining that temper tantrums are normal during this stage of development helps reassure the parent and provides a better understanding of their child’s behavior.
Choice D rationale
While diet can play a role in behavior, the nurse’s response should focus on normalizing the child’s behavior and providing reassurance. Discussing diet may not address the parent’s immediate concern about temper tantrums and difficult behaviors.
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