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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

Answer and Explanation

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.

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

Explanation

A. While age is considered in growth charts, it is not an anthropometric measurement.

B. BMI is an important indicator of nutritional status and helps assess underweight, healthy weight, or overweight status.

C. Vital signs are not part of anthropometric measurements.

D. Height is a key anthropometric measure used to assess growth and development.

E. Weight is a fundamental anthropometric measure for assessing nutritional status.

F. Routine laboratory tests are not part of anthropometric measurements but may complement the assessment.

A. Guided imagery B. Activity C. Acetaminophen D. High protein diet E. Warm compress F. Opioids

Correct Answer is ["A","C","E"]

Explanation

A. Guided imagery can help preschoolers manage mild to moderate pain by promoting relaxation and distraction.

B. Engaging in activity may increase discomfort and should be limited during acute pain.

C. Acetaminophen is appropriate for managing mild to moderate pain in preschoolers.

D. A high-protein diet is important for overall healing but does not directly address acute pain.

E. Warm compresses can provide comfort and relieve musculoskeletal discomfort.

F. Opioids are typically reserved for severe pain and not the first-line treatment for preschoolers with mild to moderate pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the nutritional status of a child using anthropometric evaluations. Which of the following should the nurse include in the assessment? (Select All that Apply.)

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

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Correct Answer is ["A","C","E"]

Explanation

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