A nurse has just received handoff communication at the start of their shift. After reviewing each client’s status, which of the following clients should the nurse see first?
A 6-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hours ago.
A 15-year-old adolescent who had a laparoscopic appendectomy 30 hours ago, rates their pain as 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 O2 saturation of 91%.
An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hours and ate 90% of their meals.
The Correct Answer is C
Choice A: A 6-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hours ago
Asthma exacerbations can be serious, but this child used a rescue inhaler 16 hours ago, suggesting that the immediate crisis may have passed. However, the nurse should still monitor the child closely for any signs of worsening symptoms, such as increased difficulty breathing or decreased oxygen saturation. The child’s condition is stable enough to not require immediate attention compared to other options.
Choice B: A 15-year-old adolescent who had a laparoscopic appendectomy 30 hours ago, rates their pain as 3 on a scale of 1 to 10, and is preparing for discharge this morning
Postoperative care is important, but this adolescent’s pain level is relatively low (3 out of 10), and they are preparing for discharge. This indicates that their condition is stable and they are recovering well. Therefore, they do not require immediate attention compared to other patients.
Choice C: A 3-year-old toddler who aspirated several sunflower seeds and continues to cough with an O2 saturation of 91%
Aspiration of foreign objects can lead to serious complications, including airway obstruction and infection. The toddler’s continued coughing and low oxygen saturation (91%) indicate that they are not getting enough oxygen, which is a critical situation. Immediate intervention is necessary to prevent further respiratory compromise and potential complications such as pneumonia or respiratory failure.
Choice D: An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hours and ate 90% of their meals
This infant’s condition appears to be improving, as indicated by the number of wet diapers and their food intake. While dehydration can be serious, the signs suggest that the infant is responding well to treatment and is not in immediate danger. Therefore, they do not require urgent attention compared to the toddler with aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Decreased stridor: Stridor is a high-pitched, wheezing sound caused by disrupted airflow. In acute laryngotracheobronchitis (croup), stridor is a common symptom due to inflammation and narrowing of the airways. The effectiveness of treatment, such as a cool mist tent, is often indicated by a reduction in stridor, as it suggests that the airway inflammation is decreasing and the airflow is improving.
Choice B reason:
Improved hydration: While maintaining hydration is important in managing croup, it is not a direct indicator of the effectiveness of the cool mist tent treatment. Improved hydration can be achieved through various means, such as oral fluids or intravenous therapy, and does not specifically reflect the reduction of airway inflammation.
Choice C reason:
Decreased temperature: Fever can be a symptom of croup, but a decrease in temperature is not a primary indicator of the effectiveness of the cool mist tent treatment. The main goal of the cool mist tent is to reduce airway inflammation and improve breathing, rather than to control fever.
Choice D reason:
Barking cough: A barking cough is a characteristic symptom of croup. While the cool mist tent can help soothe the airways and reduce coughing, the presence or absence of a barking cough alone is not a definitive indicator of treatment effectiveness. The primary focus is on reducing airway obstruction and improving airflow.
Correct Answer is C
Explanation
Choice A Reason:
Blood pressure. While blood pressure can be an indicator of fluid loss, it is not the most reliable indicator in infants. Blood pressure can remain normal until significant fluid loss has occurred. Therefore, it is not the best measure for early detection of dehydration in infants.
Choice B Reason:
Respiratory rate. An increased respiratory rate can be a sign of dehydration, but it is not the most reliable indicator. Respiratory rate can be influenced by many factors, including fever and respiratory infections, making it less specific for assessing fluid loss.
Choice C Reason:
Body weight. This is the most reliable indicator of fluid loss in infants. A significant decrease in body weight is a direct measure of fluid loss. Monitoring changes in body weight can help healthcare providers accurately assess the degree of dehydration and guide appropriate treatment.
Choice D Reason:
Skin turgor. Skin turgor can be an indicator of dehydration, but it is not the most reliable measure. In infants, skin turgor can be affected by factors such as malnutrition and skin elasticity, making it less specific for assessing fluid loss compared to body weight.
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