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 C
Explanation
A. A permissive style lacks structure and discipline, often leading to poor self-regulation, but frequent discipline is not a typical characteristic.
B. An authoritative style does involve input from children, but the focus is more on communication and reasoning.
C. An authoritative parenting style promotes open communication, sets clear expectations, and uses reasoning, leading to better child outcomes.
D. An uninvolved parenting style is characterized by neglecting the child’s needs and providing minimal structure or support.
Correct Answer is D
Explanation
A. Asking "who, what, where, and why" questions typically occurs around age 3 to 4 years.
B. Following one-step directions is typically seen earlier, around 12 to 15 months.
C. Recognizing items in a picture book is more characteristic of a 12-month-old child.
D. By 18 months, toddlers often begin to combine two words, such as "want cookie" or "go outside."
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