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 statement shows that the parents understand that toddlers need a balanced diet that includes a variety of foods from different food groups. The quality of food is more important than the quantity, as toddlers may have erratic eating patterns and may not consume large amounts of food at one time.
Choice B reason: This statement is incorrect, as toddlers typically have a decreased appetite compared to infants. This is due to their slower growth rate and increased interest in other activities. Parents should not force their toddlers to eat more than they want, but rather offer them healthy snacks and meals throughout the day.
Choice C reason: This statement is incorrect, as toddlers do not need vitamin supplements unless they have a specific deficiency or medical condition. Giving vitamins to a picky eater may not address the underlying causes of their food preferences, such as texture, taste, or appearance. Parents should encourage their toddlers to try new foods and avoid using food as a reward or punishment.
Choice D reason: This statement is incorrect, as toddlers do not need 3,000 calories per day. The average daily caloric intake for a toddler is about 1,000 to 1,400 calories, depending on their age, weight, and activity level. Parents should not overfeed their toddlers or give them high-calorie foods that may lead to obesity or malnutrition.
Correct Answer is D
Explanation
Choice A reason: A low-sodium diet is not recommended for a child who has Addison's disease, as they need more sodium to maintain their blood pressure and fluid balance. A high-sodium diet may be advised instead. ¹
Choice B reason: Hyperglycemia, or high blood sugar, is not a common manifestation of Addison's disease, as the condition causes low levels of cortisol, which normally raises blood sugar. Hypoglycemia, or low blood sugar, is more likely to occur and should be monitored and treated. ²
Choice C reason: Fluid volume excess, or edema, is not a common complication of Addison's disease, as the condition causes low levels of aldosterone, which normally retains sodium and water in the body. Fluid volume deficit, or dehydration, is more likely to occur and should be prevented and corrected. ³
Choice D reason: Cortisol replacement therapy is the main treatment for Addison's disease, as it helps restore the normal function of the adrenal glands and prevent adrenal crisis. The parents should be taught about the dosage, timing, and side effects of the medication, as well as the signs and symptoms of underdose and overdose. They should also be instructed to increase the dose during times of stress, illness, or injury, and to carry an emergency injection kit. ⁴.
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