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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

Answer and Explanation

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.

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Correct Answer is ["B","E","F"]

Explanation

A. Cold compresses may not be appropriate in this case. In sickle cell crises, warmth is typically encouraged to promote circulation and reduce pain, whereas cold can constrict blood vessels and potentially worsen ischemia.

B. Bedrest is appropriate for this client to minimize energy expenditure and allow the body to focus on healing. Pain management is also a priority, and limiting activity can help manage pain levels.

C. While oxygen can be helpful in managing hypoxia, the client’s oxygen saturation is currently 96% on room air, indicating adequate oxygenation. Routine administration of oxygen is not indicated in this scenario.

D. In sickle cell disease, hydration is important to reduce blood viscosity and prevent crises. Therefore, the nurse should encourage adequate fluid intake unless contraindicated.

E. The client has a significantly low hemoglobin level (5 g/dL), which may necessitate a blood transfusion to improve oxygen-carrying capacity and treat anemia. Consent should be obtained as part of the preparation for this intervention.

F. Administering IV fluids is essential for rehydration and improving circulation, which can help alleviate pain and prevent further sickling of cells.

G. While passive range-of-motion exercises can be beneficial, they are generally not recommended during acute pain episodes as they may exacerbate discomfort and pain. The focus should be on pain management and rest.

Correct Answer is ["300"]

Explanation

To calculate the dose of ceftriaxone for the child, first convert the child's weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds. The child weighs 33 pounds, which is approximately 15 kilograms when divided by 2.2. The prescribed dose is 60 mg/kg/day, so for a 15 kg child, this would be 900 mg per day. Since the medication is to be administered in three divided doses, you would divide 900 mg by 3, resulting in 300 mg per dose.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for an adolescent client. Exhibits Which of the following actions should the nurse plan to take? (Select all that apply.)

Correct Answer is ["B","E","F"]

Explanation

Correct Answer is ["300"]

Explanation

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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.