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 A
Explanation
The correct answer is Choice A.
Choice A rationale
The apex of the heart (apical pulse) is the preferred site for assessing the heart rate in infants. It is located at the point of maximal impulse (PMI) and provides the most accurate measurement of the heart rate in this age group.
Choice B rationale
The brachial artery is not the preferred site for assessing the heart rate in infants. While it can be used for blood pressure measurement, it is not as accurate as the apical pulse for heart rate assessment.
Choice C rationale
The radial artery is not typically used for assessing the heart rate in infants. It is more commonly used in older children and adults.
Choice D rationale
The carotid artery is not recommended for assessing the heart rate in infants due to the risk of compressing the airway and causing discomfort.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Wilms tumor, also known as nephroblastoma, is a type of kidney cancer that primarily affects children. It is crucial not to palpate the abdomen of a child with a suspected Wilms tumor because this can cause the tumor to rupture and spread cancerous cells to other parts of the body.
Choice B rationale
This choice is incorrect because there is no specific restriction on venipuncture or blood pressure measurements in the left arm for children with Wilms tumor. This precaution is typically associated with conditions like lymphedema or after a mastectomy.
Choice C rationale
Collecting all urine is not a specific precaution for Wilms tumor. While monitoring urine output can be important in various conditions, it is not a primary concern for Wilms tumor.
Choice D rationale
Contact precautions are not necessary for Wilms tumor as it is not an infectious disease. Contact precautions are typically used for conditions that are contagious or spread through direct contact.
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