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.

Answer and Explanation

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.

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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.

A. I give my child aspirin to reduce his fever. B. I give my child ibuprofen when his muscles are aching. C. I am leaving a humidifier on in my child’s room when he naps. D. I am encouraging my child to drink grapefruit juice.

Correct Answer is A

Explanation

Choice A Reason:

Aspirin is strongly associated with an increased risk of Reye syndrome in children, especially when given during a viral illness like influenza or chickenpox. Reye syndrome is a rare but serious condition that causes swelling in the liver and brain. The use of aspirin in children with viral infections can lead to this condition, making it crucial to avoid aspirin and instead use alternatives like acetaminophen or ibuprofen for fever and pain relief.

Choice B Reason:

Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is generally considered safe for use in children to relieve pain and reduce fever. Unlike aspirin, ibuprofen does not carry the same risk of causing Reye syndrome. Therefore, giving ibuprofen to a child with influenza for muscle aches does not increase the risk of Reye syndrome.

Choice C Reason:

Using a humidifier in a child’s room can help alleviate symptoms of respiratory infections by keeping the air moist, which can soothe irritated airways and reduce congestion. This practice does not increase the risk of Reye syndrome and is generally considered a safe and supportive measure for children with influenza.

Choice D Reason:

Encouraging a child to drink grapefruit juice can be beneficial for hydration and providing essential vitamins. However, it has no direct connection to the risk of Reye syndrome. While grapefruit juice can interact with certain medications, it does not increase the risk of developing Reye syndrome in children with influenza.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings indicates that the treatment has been effective?

Correct Answer is A

Explanation

A nurse is caring for a child who has influenza. The nurse should identify which of the following statements by the parent indicates the child has an increased risk for Reye syndrome?

Correct Answer is A

Explanation

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