A nurse is caring for a school-age child who has leukemia.
Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.
Skin assessment.
Oxygen saturation.
WBC count.
Retractions.
Upper respiratory infection.
Breath sounds.
Respiratory rate.
Correct Answer : A,B,C,D,E
Choice A rationale
The skin assessment reveals bruising and petechiae, which are signs of thrombocytopenia, a condition where the blood has a lower than normal number of platelets. This is significant in a child with leukemia as it may indicate a relapse or bone marrow suppression. The presence of petechiae and unexplained bruising should be reported to the provider as they can be indicative of bleeding disorders or a decrease in platelet count.
Choice B rationale
Oxygen saturation of 92% on room air is below the normal range (95-100%) for a child. This indicates hypoxemia, which can be a sign of respiratory distress or other underlying conditions. Given the child’s history of an upper respiratory infection and leukemia, this finding is critical and should be reported to the provider to ensure appropriate interventions are taken to improve oxygenation.
Choice C rationale
The WBC count is crucial in a child with leukemia. An abnormal WBC count can indicate an infection, relapse, or bone marrow suppression. Monitoring the WBC count helps in assessing the child’s immune status and the effectiveness of the leukemia treatment. Any significant changes in the WBC count should be reported to the provider for further evaluation and management.
Choice D rationale
Subcostal retractions are a sign of increased work of breathing and respiratory distress. This finding, along with the child’s statement of feeling like they can’t breathe, indicates that the child is struggling to maintain adequate ventilation. Reporting this to the provider is essential for timely intervention to prevent further respiratory compromise.
Choice E rationale
An ongoing upper respiratory infection for the last 2 months that has not resolved is concerning, especially in a child with a history of leukemia. This could indicate an underlying immunodeficiency or a more serious infection that requires further investigation and treatment. Reporting this to the provider is necessary to address the persistent infection and prevent complications.
Choice G rationale
The respiratory rate is an important vital sign that can indicate respiratory distress or other underlying conditions. An abnormal respiratory rate, whether too high or too low, can be a sign of respiratory or metabolic issues. Monitoring and reporting the respiratory rate to the provider helps in assessing the child’s respiratory status and determining the need for further intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Encouraging the client to increase fluid intake is correct. Increasing fluid intake helps to maintain hydration, which is essential for the body to function properly, especially when the client is experiencing fever and muscle aches. Hydration helps to thin mucus, making it easier to expel, and supports the immune system in fighting off infection.
Choice B rationale
Placing the client in a private room is correct. A private room helps to prevent the spread of infection to other patients and healthcare workers. This is particularly important when the client has symptoms such as fever, sore throat, and fatigue, which could indicate a contagious illness.
Choice C rationale
Placing the client on contact precautions is incorrect. Contact precautions are typically used for infections that are spread by direct contact with the patient or their environment, such as MRSA or C. difficile. The symptoms described (headache, muscle aches, fever, sore throat, and fatigue) do not necessarily indicate an infection that requires contact precautions.
Choice D rationale
Wearing a mask when caring for the client is correct. Wearing a mask helps to prevent the transmission of respiratory infections, which can be spread through droplets when the client coughs or sneezes. This is especially important when the client has symptoms such as a sore throat and fever, which could indicate a respiratory infection.
Correct Answer is B
Explanation
Choice A rationale
Supraventricular tachycardia (SVT) is characterized by a rapid heart rate originating above the ventricles, typically with a regular rhythm and identifiable P waves. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with SVT5.
Choice B rationale
Atrial fibrillation (AF) is characterized by an irregularly irregular rhythm, absence of identifiable P waves, and variable PR intervals. The ECG findings of an irregular rhythm, inability to identify P waves, and a QRS duration of 0.10 seconds are consistent with AF6.
Choice C rationale
Sinus bradycardia is characterized by a regular rhythm with a heart rate less than 60 beats per minute and identifiable P waves preceding each QRS complex. The described ECG strip shows an irregular rhythm and an inability to identify P waves, which is not consistent with sinus bradycardia.
Choice D rationale
First-degree heart block is characterized by a prolonged PR interval with a regular rhythm. The described ECG strip shows an irregular rhythm and an inability to measure the PR interval, which is not consistent with first-degree heart block.
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