A nurse is planning care for a group of clients following change-of-shift report. When using clinical decision making, which of the following clients should the nurse assess first?

A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube

A preschooler awaiting discharge instructions prior to leaving the hospital

A toddler who has a respiratory rate of 54/min

A school-age child who reports nausea following chemotherapy

Answer and Explanation

The Correct Answer is C

A) A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube: While this child requires regular monitoring and care, they are in a stable postoperative phase and do not show signs of acute distress that necessitate immediate attention over other clients.

B) A preschooler awaiting discharge instructions prior to leaving the hospital: This client is stable enough to be considered for discharge. While discharge instructions are important, they do not take priority over a client with potential respiratory distress.

C) A toddler who has a respiratory rate of 54/min: This client exhibits a significantly elevated respiratory rate, which can indicate respiratory distress or a serious underlying condition. Immediate assessment and intervention are necessary to ensure the toddler's airway and breathing are managed appropriately.

D) A school-age child who reports nausea following chemotherapy: While nausea following chemotherapy is uncomfortable and needs management, it is a known side effect and typically not life-threatening. This client's condition is less urgent compared to a toddler showing signs of potential respiratory distress.

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Correct Answer is C

Explanation

A) Decreased systolic blood pressure: In older adults, systolic blood pressure often increases due to stiffening of the arteries rather than decreasing. This increase in systolic blood pressure is due to reduced elasticity in blood vessels, making it a common physiological change.

B) Decreased anteroposterior chest diameter: In fact, the anteroposterior chest diameter often increases with age due to changes in the rib cage and spine, such as kyphosis. An increased chest diameter is observed in older adults, not a decrease.

C) Increased cerumen thickness: As people age, cerumen (earwax) production can increase and the cerumen can become thicker and drier. This is due to changes in the ceruminous glands and can lead to more frequent earwax impaction in older adults, making it a relevant point to include in the educational program.

D) Increased saliva production: Typically, older adults experience a decrease in saliva production, not an increase. Reduced saliva production can contribute to difficulties with chewing, swallowing, and oral health.

A. Drink 8 oz of milk when hypoglycemia develops. B. Initiate a 1,400-calorie diet daily. C. Rotate the insulin injection site to a different area of the body with every other injection. D. Keep unopened insulin refrigerated at 4.44° C (40° F).

Correct Answer is D

Explanation

A) Drink 8 oz of milk when hypoglycemia develops:
While consuming a fast-acting carbohydrate is important during hypoglycemia, 8 oz of milk may not be the most effective choice. Typically, glucose tablets or juice are recommended as they provide a quicker absorption of sugar into the bloodstream.

B) Initiate a 1,400-calorie diet daily:
Caloric needs should be individualized based on the adolescent’s age, weight, activity level, and overall health. A fixed 1,400-calorie diet might not be appropriate for every adolescent and could lead to insufficient energy intake or excessive restriction.

C) Rotate the insulin injection site to a different area of the body with every other injection:
While rotating injection sites is important to prevent lipodystrophy, it is generally recommended to use different sites within the same area (such as different spots on the abdomen) rather than entirely different areas of the body with each injection. This ensures consistent absorption of insulin.

D) Keep unopened insulin refrigerated at 4.44° C (40° F):
Unopened insulin should be stored in the refrigerator to maintain its potency until it is ready to be used. This temperature range ensures the insulin remains stable and effective for use.

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A nurse is planning care for a group of clients following change-of-shift report. When using clinical decision making, which of the following clients should the nurse assess first?

Nursing Test Bank

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