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 ["50"]
Explanation
Step 1 is: Calculate the total volume to be infused. 150 mL/hr × 12 hr = 1800 mL Step 2 is: Calculate the total drops per minute. (1800 mL ÷ 720 min) × 20 gtt/mL = 50 gtt/min
The final calculated answer is 50 gtt/min.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.
Choice B rationale
Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.
Choice C rationale
Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.
Choice D rationale
Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.
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