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. Cuff size recommendations vary based on the child’s arm circumference, not a specific range for all school-aged children.
B. The cuff should fit snugly around the child's arm, not loosely, to obtain an accurate reading.
C. Blood pressure is typically measured over the brachial artery using a manual or automated cuff.
D. Routine blood pressure screening usually begins at age 3 unless there are specific indications to begin earlier.
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.
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