A nurse is reviewing laboratory results of a school-age child who is 1 week
postoperative following an open fracture repair. Which of the following
... [Show More] values
should the nurse identify as an indication of a potential complication
A. Erythrocyte sedimentation rate 18 mm/hr
B. WBC 6,200/mm3C.
C-reactive protein 1.4 mg/L
D. RBC 4.7 106/µL - A. Erythrocyte sedimentation rate 18 mm/hr
The nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is
above the expected reference range of up to 10 mm/hr and is an indication of
osteomyelitis.
A nurse is planning care for a school-age child who has a tunneled central venous
access device. Which of the following interventions should the nurse include in the
plan
A. Use sterile scissors to remove the dressing from the site.
B. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when
not in use.
C. Access the site using a noncoring angled needle.
D. Use a semipermeable transparent dressing to cover the site. - D. Use a
semipermeable transparent dressing to cover the site.
The nurse should cover the site with a semipermeable transparent dressing to
reduce the risk of infection.
A nurse is planning care to address nutritional needs for a preschooler who has
cystic fibrosis. Which of the following interventions should the nurse include in the
plan?
A. Administer pancreatic enzymes 2 hr after meals.
B. Decrease pancreatic enzymes if steatorrhea develops.
C. Limit fluid intake to 750 mL per day.
D. Increase fat content in the child's diet to 40% of total calories. - D. Increase fat
content in the child's diet to 40% of total calories.
A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of
the pancreas and limited secretion of pancreatic enzymes. The nurse should
increase the child's fat intake to 35% to 40% of total caloric intake.
A nurse in an emergency department is auscultating the lungs of an adolescent who
is experiencing dyspnea. The nurse should identify the sound as which of the
following?
A. Wheezes
B. Crackles
C. Pleural friction rub
D. Rhonchi - A. Wheezes
The nurse should identify the sound during auscultation as wheezes, which are
high-pitched, musical or whistling-like sounds heard primarily on expiration as air
passes through and vibrates narrowed airways.
A nurse is assessing a school-age child who has an infratentorial brain tumor.
Which of the following findings should the nurse identify as a manifestation of
increased intracranial pressure?
A. Hypotension
B. Reports insomnia
C. Difficulty concentrating
D. Tachycardia - C. Difficulty concentrating
The nurse should identify that irritability, inability to follow commands, and
difficulty concentrating are manifestations of increased intracranial pressure due to
decreased blood flow within the brain and pressure on the brainstem.
A nurse is assessing an infant who has pneumonia. Which of the following
findings is the priority for the nurse to report the provider?
A. Nasal flaring
B. WBC count 11,300/mm3
C. Diarrhea
D. Abdominal distension - A. Nasal flaring
When using the airway, breathing, and circulation approach to client care, the
nurse should determine that the priority finding to report to the provider is nasal
flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress. [Show Less]