Nurse is reviewing lab results of a school age child 1 week postop following an
open fracture repair. Which findings should nurse ID as indication of
... [Show More] potential
complication?
Erythrocyte sedimentation rate 18 mm/hr
WBC count 6,200/mm3
C-reactive protein 1.4 mg/L
RBC count 4.7 million/mm3 - ANS: Erythrocyte sedimentation rate 18 mm/hr:
- above the expected reference range of up to 10 mm/hr and is an indication of
osteomyelitis.
WBC count 6,200/mm3:
- within the expected reference range of 5,000 to 10,000/mm3. An elevated WBC
count is an indication of osteomyelitis.
C-reactive protein 1.4 mg/L:
- within the expected reference range of <10.0 mg/L. An elevated C-reactive
protein level is an indication of osteomyelitis.
RBC count 4.7 million/mm3:
- within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC
count can indicate hemorrhage.
Nurse planning care for school age child with tunneled CVA device. Which
interventions should the nurse include in plan?
Use sterile scissors to remove the dressing from the site.
Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not
in use
Access the site using a noncoring angled needle
Use a semipermeable transparent dressing to cover the site - Use sterile scissors to
remove the dressing from the site:
- The nurse should avoid the use of scissors when performing dressing changes
because this can result in accidental cutting of the catheter.
Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not
in use:
- The nurse should flush each lumen of the catheter with a heparin solution daily
when not in use.
Access the site using a noncoring angled needle:
- The nurse should use a noncoring angled or straight needle when accessing an
implanted port.
ANS: 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.
Nurse is planning care to address nutritional needs for preschooler with cystic
fibrosis. Which interventions should the nurse include in plans?
Administer pancreatic enzymes 2 hr after meals.
Discontinue the use of pancreatic enzymes if steatorrhea develops.
Limit fluid intake to 750 mL per day.
Increase fat content in the child's diet to 40% of total calories. - Administer
pancreatic enzymes 2 hr after meals:
- The nurse should plan to administer pancreatic enzymes within 30 min of meals
and snacks to replace the enzymes lost with cystic fibrosis.
Discontinue the use of pancreatic enzymes if steatorrhea develops:
- A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might
need to have their dosage of pancreatic enzyme increased by their provider until
the steatorrhea resolves.
Limit fluid intake to 750 mL per day:
- The nurse should encourage fluid intake, rather than restrict it, to prevent
dehydration caused by the loss of sodium and chloride through perspiration.
ANS: 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.
Nurse in ED auscultates lungs of adolescent experiencing dyspnea. Nurse should
ID sound as what?
Wheezes
Crackles
Pleural friction rub
Rhonchi - ANS: Wheezes:
- high-pitched, musical or whistling-like sounds heard primarily on expiration as
air passes through and vibrates narrowed airways. [Show Less]