A nurse has just received hand-off communication at the start of their shift. After reviewing each client's status, which of the following clients should the nurse see first?
An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hr and ate 90% of their meals
A 15-year-old adolescent who had a laparoscopic appendectomy 30 hr ago, rates their pain a 3 on a scale of 1 to 10, and is preparing for discharge this morning
A 3-year-old toddler who aspirated several sunflower seeds and continues to cough with an O. saturation of 91%
A 6-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hr ago
Child's statements with parent input
The Correct Answer is C
A. The 18-month-old shows signs of improving hydration status, evidenced by adequate wet diapers and food intake. This client is stable.
B. The adolescent with mild postoperative pain and preparing for discharge is stable and does not require immediate attention.
C. The toddler's low oxygen saturation (91%) and continued coughing indicate potential airway obstruction or impaired gas exchange, which requires immediate assessment and intervention to prevent respiratory failure.
D. Although the 6-year-old with asthma should be monitored, their last use of a rescue inhaler 16 hours ago suggests they are not in acute distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. CSF analysis is the primary diagnostic test for meningitis, which presents with fever, headache, stiff neck, and rash.
B. The Glasgow Coma Scale (GCS) assesses consciousness but does not confirm the diagnosis of meningitis.
C. An RBC count is unrelated to diagnosing meningitis.
D. MRI can identify structural brain abnormalities but is not the first-line diagnostic test for meningitis.
Correct Answer is C
Explanation
A. The 18-month-old shows signs of improving hydration status, evidenced by adequate wet diapers and food intake. This client is stable.
B. The adolescent with mild postoperative pain and preparing for discharge is stable and does not require immediate attention.
C. The toddler's low oxygen saturation (91%) and continued coughing indicate potential airway obstruction or impaired gas exchange, which requires immediate assessment and intervention to prevent respiratory failure.
D. Although the 6-year-old with asthma should be monitored, their last use of a rescue inhaler 16 hours ago suggests they are not in acute distress.
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