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A pediatric nurse is assisting with the care of a school-age child who has leukemia.

Exhibits
Which of the following data collection findings should the nurse report to the provider? Select the 5 findings that should be reported to the provider.

Blood pressure

Skin assessment

Breath sounds

Oxygen saturation

WBC count

Retractions

Respiratory rate

Hemoglobin

Answer and Explanation

Correct Answer : B,C,D,F,G

A. Blood pressure: The blood pressure is within normal limits and does not indicate an acute issue in this context.

B. Skin assessment: The presence of pallor and bruising indicates potential anemia and thrombocytopenia, common in leukemia patients but concerning signs that need to be monitored.

C. Breath sounds: Rhonchi in the upper lobes suggest respiratory congestion or infection, which is dangerous in an immunocompromised child.

D. Oxygen saturation: A drop in oxygen saturation to 90% indicates impaired oxygenation, which could signify respiratory distress or worsening infection.

E. WBC count: Although WBC count is within the low-normal range, it does not independently indicate an immediate change in the child’s condition.

F. Retractions: Subcostal retractions indicate respiratory distress, which is critical to report as it could escalate quickly in a child.

G. Respiratory rate: The increased respiratory rate (from 22 to 30/min) reflects respiratory distress and may worsen if the infection progresses.

H. Hemoglobin: While low, the hemoglobin is not acutely life-threatening in this case and would not necessarily prompt urgent intervention without other symptoms.

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Correct Answer is C

Explanation

A. Hip: While “hip” can sometimes colloquially refer to the iliac crest, it is not commonly used to describe the specific site for aspiration outside of the iliac crest.

B. Cervical spine: The cervical spine is not a site used for bone marrow aspiration due to its inaccessibility and proximity to critical structures.

C. Sternum: The sternum is a common site for bone marrow aspiration in adults as it provides direct access to the marrow.

D. Humerus: The humerus is generally not used for bone marrow aspirations as it does not provide as accessible or large an area for aspiration.

A. Progressive increase in platelet production. B. Excessive thrombosis and bleeding. C. Immediate sodium and fluid retention. D. Increased clotting factors.

Correct Answer is B

Explanation

A. Progressive increase in platelet production: In DIC, platelets are rapidly consumed, not increased, due to widespread clotting in the blood vessels.

B. Excessive thrombosis and bleeding: DIC is a complex condition where there is widespread activation of the clotting cascade, leading to excessive clotting and subsequent depletion of platelets and clotting factors, resulting in both thrombosis and bleeding.

C. Immediate sodium and fluid retention: Sodium and fluid retention are not specific findings in DIC; they may occur in cases of renal or heart failure but are unrelated to the clotting issues in DIC.

D. Increased clotting factors: In DIC, clotting factors are depleted as they are used up in widespread clotting, leading to bleeding when factors are exhausted.

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A pediatric nurse is assisting with the care of a school-age child who has leukemia. Exhibits Which of the following data collection findings should the nurse report to the provider? Select the 5 findings that should be reported to the provider.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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A pediatric nurse is assisting with the care of a school-age child who has leukemia.

Exhibits
Which of the following data collection findings should the nurse report to the provider? Select the 5 findings that should be reported to the provider.