A nurse in an urgent care clinic is prioritizing care for four children. Which of the following children should the nurse assess first?
A toddler who has nephrotic syndrome and facial edema.
An adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lb).
A preschool-age child who has a muffled voice and no spontaneous cough.
A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL.
The Correct Answer is C
A preschool-age child who has a muffled voice and no spontaneous cough should be assessed first.
These symptoms may indicate epiglottitis, which is a life-threatening condition that requires immediate medical attention.
Choice A, B and D are also important but not as urgent as choice C. A toddler with nephrotic syndrome and facial edema, an adolescent with Crohn’s disease and recent weight loss, and a school-age child with diabetes mellitus and a blood glucose of 200 mg/dL should be assessed after the preschool-age child with a muffled voice and no spontaneous cough.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should position the opening of the bag over the urethra and the anus.
Choice B is wrong because placing a snug-fitting diaper over the drainage bag is not necessary.
Choice C is wrong because there is no need to apply lidocaine gel to the perineum before attaching the bag.
Choice D is wrong because there is no need to stretch the perineum taut when applying the bag.
Correct Answer is B
Explanation
This is because oxygen saturation below 90% indicates that the infant is not getting enough oxygen and central cyanosis (bluish color of the skin due to lack of oxygen) is a sign of severe respiratory distress.
Both of these findings require immediate medical attention.
Choice A is wrong because cough or difficulty in breathing, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice C is wrong because severe respiratory distress (e.g grunting, very severe chest indrawing), while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
Choice D is wrong because signs of pneumonia with a general danger, while concerning, may not require immediate reporting to the provider as they are common symptoms of RSV infection.
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