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:
The statement “I will report a change in her breathing” is appropriate. Changes in breathing can indicate worsening of the upper respiratory infection or complications such as diabetic ketoacidosis (DKA), which requires immediate medical attention. Reporting such changes is crucial for timely intervention.
Choice B Reason:
The statement “I will notify the doctor if her temperature is not controlled with acetaminophen” is also appropriate. Persistent fever despite acetaminophen can indicate a more serious infection or other complications that need medical evaluation. This ensures that the child receives appropriate care and treatment.
Choice C Reason:
The statement “I will encourage her to drink half a cup of water or sugar-free fluids every 30 minutes” is correct. Staying hydrated is essential, especially for a child with diabetes, to prevent dehydration and help manage blood sugar levels. Sugar-free fluids are recommended to avoid spikes in blood sugar.
Choice D Reason:
The statement “I will continue to check her blood sugar two times per day when she is sick” indicates a need for further instruction. When a child with type 1 diabetes is sick, blood sugar levels can fluctuate more than usual. It is generally recommended to check blood sugar levels more frequently, such as every 3-4 hours, to ensure they remain within a safe range and to detect any signs of hyperglycemia or hypoglycemia early.
Correct Answer is C
Explanation
Choice A Reason:
Give the child a chlorine bath twice daily. This is not recommended for treating impetigo contagiosa. Chlorine baths are not a standard treatment for impetigo and can cause skin irritation. Instead, the focus should be on maintaining good hygiene and using prescribed topical or oral antibiotics to treat the infection.
Choice B Reason:
Immunize household contacts for the disease. This is not applicable for impetigo contagiosa. Impetigo is a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes, and there is no vaccine available for it. Preventive measures should focus on good hygiene practices and avoiding close contact with infected individuals.
Choice C Reason:
Wash clothing in hot water. This is the correct intervention. Washing clothing, bed linens, and towels in hot water helps to kill the bacteria that cause impetigo and prevent the spread of the infection. It is an important step in managing and controlling the spread of impetigo contagiosa.
Choice D Reason:
Keep the child on droplet precautions at home. This is not necessary for impetigo contagiosa. Droplet precautions are typically used for respiratory infections that spread through respiratory droplets. Impetigo spreads through direct contact with the infected skin or contaminated items, so standard contact precautions and good hygiene practices are sufficient.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.