Exhibits
Which of the following assessment findings should the nurse report to the provider? Select the 6 findings that should be reported to the provider.
WBC count
Hemoglobin
Upper respiratory infection
Breath sounds
Oxygen saturation
Retractions
Respiratory rate
Skin assessment
Correct Answer : A,B,D,E,F,H
A. The WBC count is elevated at 15,000/mm³, which indicates leukocytosis. In a child with leukemia, this could suggest a potential relapse or an ongoing infection, which requires prompt evaluation by the provider.
B. The hemoglobin level is at the lower limit of normal (10 g/dL). This can indicate anemia, which is significant in a child with a history of leukemia and may require further investigation or intervention.
C. While the ongoing upper respiratory infection is concerning, it is less urgent than the other findings. The nurse should monitor this but may not need to report it as a critical finding compared to the child's acute symptoms.
D. The presence of clear breath sounds is expected; however, they should be reported in the context of the child's respiratory distress and the associated findings.
E. An oxygen saturation of 92% on room air is below the normal range and indicates hypoxia. This is a critical finding that requires immediate attention from the provider.
F. Subcostal retractions indicate increased work of breathing and respiratory distress, which is an urgent assessment finding that must be communicated to the provider.
G. While the respiratory rate is relevant, the specific number was not provided, and unless it indicates significant distress or abnormality, it may not be a priority report compared to the other findings.
H. The presence of petechiae is concerning, especially in a child with a history of leukemia. This could indicate thrombocytopenia or another hematological issue, which requires further evaluation by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While monitoring temperature can be important, it is not the primary focus post-crisis unless there are specific concerns.
B. Cold compresses can constrict blood vessels and worsen sickling; heat is usually recommended for pain relief in sickle cell crisis.
C. Restricting outdoor play is not necessary; children with sickle cell anemia should be encouraged to engage in regular activities within their limits.
D. Offering fluids frequently helps prevent dehydration, which can trigger a sickle cell crisis, making it an essential part of discharge teaching.
Correct Answer is ["8"]
Explanation
To calculate the dosage of diphenhydramine (Benadryl) for the child, we first determine the total milligrams needed per dose by multiplying the child's weight in kilograms by the prescribed milligrams per kilogram. The child weighs 20 kg, so the calculation is 20 kg * 5 mg/kg, which equals 100 mg per dose. The medication is supplied at a concentration of 12.5 mg per 5 ml. To find out how many milliliters are needed to provide 100 mg, we set up a proportion: 12.5 mg/5 ml = 100 mg/x ml. Solving for x gives us x = (100 mg * 5 ml) / 12.5 mg, which equals 40 ml. Therefore, the nurse will administer 40 milliliters of the medication for one dose.
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