A nurse is caring for four children in an emergency department.
Which of the following clients should the nurse assess first?

A child who has mononucleosis and reports severe fatigue.

A child who has Wilms' tumor and an abdominal mass.

A child who has acute epiglottitis and is drooling.

A child who has a urinary tract infection and bright red blood in her urine.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

A child who has mononucleosis and reports severe fatigue requires medical attention, but this condition does not pose an immediate life-threatening risk compared to acute epiglottitis. Mononucleosis is a viral infection that can cause fatigue, sore throat, and swollen lymph nodes. While the child should be assessed, the priority is given to the child with acute epiglottitis due to the potential for airway obstruction and respiratory distress.

Choice B rationale:

A child who has Wilms' tumor and an abdominal mass also needs urgent medical evaluation. Wilms' tumor is a rare kidney cancer that primarily affects children. While it requires prompt attention, acute epiglottitis poses a more immediate threat to the airway and breathing.

Choice C rationale:

A child with acute epiglottitis and drooling requires immediate assessment and intervention. Acute epiglottitis is a potentially life-threatening infection that can cause severe swelling of the epiglottis, leading to airway obstruction. The child may have difficulty breathing and may present with the classic drooling sign due to the inability to swallow saliva. Prompt medical intervention, including airway management and appropriate antibiotics, is essential in this situation.

Choice D rationale:

A child with a urinary tract infection and bright red blood in her urine requires medical evaluation, but this condition is not as urgent as acute epiglottitis. Hematuria (blood in the urine) can have various causes, including urinary tract infections or kidney stones. While the child should receive medical attention, it does not take precedence over the immediate threat posed by acute epiglottitis, which requires urgent intervention to maintain the airway.

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Correct Answer is C

Explanation

A. Constipation is not a common complication of vacuum-assisted birth. It may be related to other factors such as dehydration, opioid use, or decreased mobility.
B. Urinary urgency is not a common complication of vacuum-assisted birth. It may be related to other factors such as bladder trauma, infection, or diuretic use.
C. Cervical laceration is a common complication of vacuum-assisted birth. It occurs when the vacuum cup causes damage to the cervix during delivery. It can lead to bleeding, infection, or cervical incompetence in future pregnancies.
D. Retained placenta is not a common complication of vacuum-assisted birth. It may be related to other factors such as placenta accreta, uterine atony, or manual removal of the placenta.

A. The last time the provider evaluated the client B. The client's most recent ventilator settings C. The time of the client's last dose of pain medication D. The frequency in which the client presses the call button E. None F. None

Correct Answer is D

Explanation

A. The time of the provider’s last evaluation provides important clinical context regarding the client’s current status and any recent changes in the plan of care. This helps the receiving team anticipate follow-up assessments and interventions.

B. The client’s most recent ventilator settings are relevant because the client was recently weaned from mechanical ventilation. This information helps evaluate respiratory stability and guides ongoing monitoring for complications after a pneumonectomy.

C. The timing of the last dose of pain medication is essential for safe and effective pain management. It allows the receiving nurse to plan subsequent doses and monitor for effectiveness or adverse effects.

D. The frequency with which the client presses the call button does not contribute meaningful clinical information for the transfer report. It does not directly affect physiological status, treatment decisions, or continuity of care.

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A nurse is caring for four children in an emergency department.Which of the following clients should the nurse assess first?

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A nurse is caring for four children in an emergency department.
Which of the following clients should the nurse assess first?