Difficulty: Medium
Average Score: 68%
Simulated
Passage / Scenario
A preschooler with acute lymphoblastic leukemia (ALL), receiving chemotherapy and steroids, no bowel movement for 5 days, crying and clinging to guardian, temperature of 38.8┬░C (101.9┬░F) tympanic, erythematous central line catheter insertion site with purulent drainage.A nurse on a pediatric unit is preparing to admit a preschooler after receiving a transfer report from a nurse in the emergency department. Which of the following findings should the nurse report to the provider immediately?
Correct answer
D
Rationale
The correct answer is D. The insertion site of the central line catheter being erythematous with purulent drainage indicates a potential infection, which can lead to sepsis in a pediatric patient. Immediate reporting to the provider is crucial for prompt intervention to prevent further complications. Reporting the other findings is important but they do not pose an immediate threat to the child's health. Choice A could indicate constipation, which is significant but not an immediate concern. Choice B suggests emotional distress, Choice C indicates fever, which may require monitoring but not immediate intervention. Therefore, choice D is the most critical finding that requires immediate action.