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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
Choice A reason: Hypovolemia is a condition of low blood volume due to fluid loss from the burn injury. It can cause decreased urine output, hypotension, tachycardia, and poor skin turgor. The nurse should monitor the client's vital signs, fluid intake and output, and weight. The nurse should administer lactated Ringer's solution to maintain urine output of 30 ml/hr.
Choice B reason: Hyperkalemia is a condition of high potassium levels in the blood due to cellular damage from the burn injury. It can cause peaked T waves, dysrhythmias, muscle weakness, and cardiac arrest. The nurse should monitor the client's serum potassium levels, electrocardiogram, and cardiac status. The nurse should avoid administering potassium-containing fluids or medications.
Choice C reason: Hypocalcemia is a condition of low calcium levels in the blood due to fluid shifts from the burn injury. It can cause positive Chvostek's sign, tetany, seizures, and hypotension. The nurse should monitor the client's serum calcium levels, neurological status, and blood pressure. The nurse should administer calcium supplements as prescribed.
Choice D reason: Hypernatremia is a condition of high sodium levels in the blood due to fluid loss from the burn injury. It can cause dry mucous membranes, thirst, agitation, and seizures. The nurse should monitor the client's serum sodium levels, hydration status, and mental status. The nurse should administer hypotonic fluids as prescribed.
Correct Answer is C
Explanation
Choice A reason: A respiratory rate of 24 breaths/min is within the normal range for a 3-year-old child. It does not indicate the degree of hydration or dehydration of the child.
Choice B reason: A heart rate of 130/min is above the normal range for a 3-year-old child, which is 80 to 120/min. It may indicate dehydration, fever, pain, or anxiety. It does not indicate the effectiveness of oral rehydration therapy.
Choice C reason: A urine specific gravity of 1.015 is within the normal range for a child, which is 1.005 to 1.030. It indicates that the child's urine is adequately concentrated and that the child is well hydrated. It is a reliable indicator of the effectiveness of oral rehydration therapy.
Choice D reason: A capillary refill of greater than 3 seconds is abnormal and indicates poor peripheral perfusion. It may be a sign of dehydration, shock, or hypothermia. It does not indicate the effectiveness of oral rehydration therapy.
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