A nurse on a pediatric unit is preparing to admit a preschooler after receiving a transfer report from a nurse in the emergency department. Which of the following findings should the nurse report to the provider immediately?
The child has not had a bowel movement for 5 days.
The child is crying and clinging to the guardian.
The child has a temperature of 38.8°C (101.9°F) tympanic.
The insertion site of the central line catheter is erythematous with a scant amount of purulent drainage.
The Correct Answer is D
Choice A reason: The child has acute lymphoblastic leukemia (ALL) and is receiving chemotherapy and steroids, which can cause constipation. The nurse should monitor the child's bowel function and provide interventions such as fluids, fiber, and laxatives as prescribed, but this is not an urgent finding.
Choice B reason: The child is in the induction phase of treatment for ALL, which can be stressful and frightening for the child and the family. The child's crying and clinging behavior indicates anxiety and fear, which are normal reactions. The nurse should provide emotional support and education to the child and the guardian, but this is not an urgent finding.
Choice C reason: The child has a fever, which is a common side effect of chemotherapy and steroids. The nurse should assess the child for other signs of infection, administer antipyretics as prescribed, and monitor the child's vital signs, but this is not an urgent finding.
Choice D reason: The child has a double-lumen central line catheter in the left chest wall, which is a potential source of infection. The erythema and purulent drainage at the insertion site indicate that the child has a local infection, which can spread to the bloodstream and cause sepsis. This is a life-threatening complication that requires immediate attention and treatment. The nurse should report this finding to the provider, obtain blood cultures, and administer antibiotics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Glyburide is an oral medication that lowers blood sugar by stimulating the pancreas to produce more insulin. It is not used for type 1 diabetes mellitus, as the pancreas cannot produce enough insulin in this condition. Glyburide is used for type 2 diabetes mellitus, which is caused by insulin resistance.
Choice B reason: Obtaining an influenza vaccine annually is recommended for people who have type 1 diabetes mellitus, as they are more prone to complications from the flu, such as pneumonia, ketoacidosis, and hospitalization. The vaccine can help prevent or reduce the severity of the flu and its complications.
Choice C reason: Injecting insulin in the deltoid muscle is not the best practice for administering insulin, as the absorption rate and onset of action may vary depending on the muscle mass and blood flow. The preferred sites for insulin injection are the abdomen, the upper arms, the thighs, and the buttocks, as they have more subcutaneous fat and less muscle tissue. The injection site should also be rotated to prevent lipodystrophy.
Choice D reason: Administering glucagon for hyperglycemia is not appropriate, as glucagon is a hormone that raises blood sugar by stimulating the liver to release glucose. It is used for hypoglycemia, or low blood sugar, which is a common and serious complication of type 1 diabetes mellitus. Hyperglycemia, or high blood sugar, is treated with insulin, fluids, and electrolytes.
Correct Answer is A
Explanation
Choice A reason: Meningitis is a possible condition, as it is an inflammation of the membranes that cover the brain and spinal cord. It can be caused by various microorganisms, such as bacteria, viruses, or fungi. The infant has many signs and symptoms of meningitis, such as fever, irritability, lethargy, bulging fontanel, and clear cerebrospinal fluid from the lumbar puncture.
Choice B reason: Hydrocephalus is not a likely condition, as it is an accumulation of cerebrospinal fluid in the brain, which causes increased intracranial pressure and enlargement of the head. The infant has a bulging fontanel, which can indicate increased intracranial pressure, but not necessarily hydrocephalus. The infant does not have other signs of hydrocephalus, such as a rapidly increasing head circumference, prominent scalp veins, or sunset eyes.
Choice C reason: Intracranial hemorrhage is not a probable condition, as it is a bleeding within the skull, which can result from trauma, vascular malformation, or coagulation disorder. The infant has retinal hemorrhages, which can indicate intracranial hemorrhage, but not necessarily. The infant does not have other signs of intracranial hemorrhage, such as seizures, vomiting, or altered mental status.
Choice D reason: Sepsis is not a definite condition, as it is a systemic inflammatory response to an infection, which can cause organ dysfunction and shock. The infant has a fever, which can indicate sepsis, but not necessarily. The infant does not have other signs of sepsis, such as tachycardia, tachypnea, hypotension, or poor perfusion.
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