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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.

A.

Blood pressure

B.

Skin assessment

C.

Breath sounds

D.

Oxygen saturation

E.

WBC count

F.

Retractions

G.

Respiratory rate

H.

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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Related Questions

Correct Answer is D

Explanation

A. Two areas of lymph nodes above and below the diaphragm: This describes stage III Hodgkin disease, where lymph node involvement occurs both above and below the diaphragm, but not necessarily in multiple organs.

B. Two or more areas on the same side of the diaphragm: This corresponds to stage II Hodgkin disease, which is limited to two or more lymph node regions on the same side of the diaphragm.

C. Localized in the cervical neck area only: Stage I Hodgkin disease typically involves a single lymph node region, often the cervical nodes, without generalized or extensive spread.

D. Generalized throughout the body within multiple organs: In stage IV Hodgkin disease, the cancer has spread beyond the lymph nodes to other organs and tissues, leading to generalized lymphadenopathy and potential organ involvement.

Correct Answer is ["1610"]

Explanation

Solution:

  1. Convert ounces to milliliters (1 oz = 30 mL):
    • Coffee: 8 oz × 30 mL = 240 mL
    • Juice: 3 oz × 30 mL = 90 mL
    • Soda: 12 oz × 30 mL = 360 mL
  2. Calculate water intake:
    • Initial pitcher: 800 mL
    • Remaining: 200 mL
    • Water intake = 800 mL - 200 mL = 600 mL
  3. Calculate IV fluids intake:
    • IV rate: 40 mL/hr
    • Time: 8 hours
    • IV fluids = 40 mL/hr × 8 hrs = 320 mL
  4. Total intake:
    • 240 mL (coffee) + 90 mL (juice) + 360 mL (soda) + 600 mL (water) + 320 mL (IV) = 1610 mL

Answer: 1610 mL

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