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 C
Explanation
Choice A reason: A 2-year-old toddler is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 2-year-old toddler may receive the meningococcal polysaccharide (MPSV4) vaccine instead, if indicated.
Choice B reason: A 4-month-old infant is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 4-month-old infant may receive the meningococcal serogroup B (MenB) vaccine instead, if indicated.
Choice C reason: An 11-year-old school-age child is a recommended recipient of the MCV4 vaccine, as it is routinely given to children aged 11 to 12 years old, with a booster dose at age 16. The MCV4 vaccine protects against four types of meningococcal bacteria (A, C, W, and Y) that can cause serious infections of the lining of the brain and spinal cord (meningitis) or the bloodstream (septicemia).
Choice D reason: A 4-year-old child is not a recommended recipient of the MCV4 vaccine, as it is not routinely given to children younger than 11 years old, unless they have certain medical conditions that increase their risk of meningococcal disease, such as asplenia, complement deficiency, or HIV infection. A 4-year-old child may receive the meningococcal polysaccharide (MPSV4) vaccine instead, if indicated.
Correct Answer is D
Explanation
Choice A reason: This is not a correct description of Bryant traction. This type of traction does not involve pins or wires inserted into the bone. It is a skin traction that uses adhesive straps or bandages attached to the skin of the lower legs.
Choice B reason: This is not a correct description of Bryant traction. This type of traction does not maintain the leg in an extended position. It flexes the hip and knee at a 90-degree angle and suspends the leg in the air.
Choice C reason: This is not a correct description of Bryant traction. This type of traction does not use a sling under the knee of the affected leg. It uses a spreader bar to keep the legs apart and prevent rotation.
Choice D reason: This is a correct description of Bryant traction. This type of traction elevates the buttocks slightly off of the bed to provide countertraction and alignment of the fractured bone.
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