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 A
Explanation
Choice A reason: This is a contraindication for the MMR immunization, which is a live attenuated vaccine. A child who has a congenital immunodeficiency may not be able to mount an adequate immune response to the vaccine and may be at risk of developing the diseases from the vaccine.
Choice B reason: This is not a contraindication for the MMR immunization. A mild fever after a previous immunization is not a sign of an allergic reaction or a serious adverse effect. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.
Choice C reason: This is not a contraindication for the MMR immunization. Taking antibiotics for otitis media does not interfere with the effectiveness or safety of the vaccine. The child can still receive the MMR immunization as long as they do not have a moderate or severe illness.
Choice D reason: This is not a contraindication for the MMR immunization. A mild cough and a low-grade fever are not signs of a moderate or severe illness that would prevent the child from receiving the vaccine. The child can still receive the MMR immunization as long as they do not have any other contraindications.
Correct Answer is D
Explanation
Choice A reason: Holding the infant's chin to his chest and knees to his abdomen during the procedure is not a correct action for the nurse to take. This position may cause spinal cord compression or respiratory distress in the infant. The nurse should position the infant on his side with his back arched and his head and knees flexed.
Choice B reason: Placing the infant in an infant seat for 2 hr following the procedure is not a correct action for the nurse to take. This position may increase the intracranial pressure and cause headaches or vomiting in the infant. The nurse should keep the infant flat or slightly elevated for 4 to 6 hr after the procedure.
Choice C reason: Keeping the infant NPO for 6 hr prior to the procedure is not a correct action for the nurse to take. This may cause dehydration or hypoglycemia in the infant. The nurse should follow the provider's orders for fasting, which are usually 2 to 4 hr for clear liquids and 4 to 6 hr for solids.
Choice D reason: Applying a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure is a correct action for the nurse to take. This is a topical anesthetic that can reduce the pain and discomfort of the needle insertion. The nurse should apply the cream to the lower back and cover it with an occlusive dressing.
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