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 D
Explanation
Choice A Reason:
Encourage the client to gently rub the affected areas. This is not recommended for clients with pruritus following treatment for scabies. Rubbing the affected areas can exacerbate the itching and potentially cause skin damage or secondary infections. Instead, clients should be advised to avoid scratching or rubbing the affected areas.
Choice B Reason:
Assist the client to take a hot shower. This is not recommended for clients with pruritus following treatment for scabies. Hot showers can dry out the skin and worsen the itching. Instead, clients should be advised to take lukewarm showers and use gentle, moisturizing cleansers to soothe the skin.
Choice C Reason:
Apply additional scabicide to the affected area. This is not recommended for clients with pruritus following treatment for scabies. Overuse of scabicide can cause skin irritation and other adverse effects. Clients should follow the prescribed treatment regimen and avoid applying additional scabicide without consulting their healthcare provider.
Choice D Reason:
Provide mittens for the client to wear at night when pruritus is typically worse. This is the correct intervention. Wearing mittens at night can help prevent the client from scratching the affected areas while sleeping, reducing the risk of skin damage and secondary infections. This is a practical and effective measure to manage pruritus following treatment for scabies.
Correct Answer is C
Explanation
Choice A Reason:
Administer meperidine every 4 hours for pain. This is not recommended for children with sickle cell anemia. Meperidine is an opioid analgesic, but it is not the preferred choice for managing pain in sickle cell patients due to its potential for causing seizures and other side effects. Instead, other pain management strategies, such as acetaminophen, NSAIDs, or other opioids like morphine, are preferred.
Choice B Reason:
Apply cold compresses to painful, swollen joints. This is not recommended for children with sickle cell anemia. Cold compresses can cause vasoconstriction, which can worsen the pain and potentially trigger a sickle cell crisis. Instead, warm compresses are recommended to help alleviate pain and promote blood flow.
Choice C Reason:
Position extremities extended. This is the correct intervention. Positioning the extremities extended helps to promote blood flow and prevent vaso-occlusive episodes, which are common in sickle cell anemia. Proper positioning can help reduce pain and improve circulation.
Choice D Reason:
Discourage a high level of fluid intake. This is not recommended for children with sickle cell anemia. Adequate hydration is crucial for preventing sickle cell crises. Encouraging a high level of fluid intake helps to keep the blood less viscous and reduces the risk of vaso-occlusive episodes. Dehydration can exacerbate the condition and lead to complications.
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