A nurse is prioritizing care for four clients.
Which of the following clients should the nurse assess first?
An adolescent who has sickle cell anemia and slurred speech.
An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10.
A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin.
A toddler who has a partial-thickness burn on his right hand and requires a dressing change.
The Correct Answer is A
An adolescent who has sickle cell anemia and slurred speech should be assessed first.
Slurred speech can be a sign of a stroke, which is a known complication of sickle cell anemia.
This requires immediate medical attention.
Choice B is wrong because while pain management is important, it is not as urgent as a potential stroke.
Choice C is wrong because while administering medication is important, it is not as urgent as a potential stroke.
Choice D is wrong because while wound care is important, it is not as urgent as a potential stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
According to UCSF Benioff Children’s Hospital Oakland Orthopaedic Department, you can change your baby’s diaper with the Pavlik harness in place and make sure the straps are kept outside of the diaper.
Choice A is wrong because while your child is being treated in the Pavlik harness, it is very important that you do not remove the harness or adjust the straps, unless you are given specific instructions by your doctor to do so.
Choice B is wrong because there are no instructions to apply lotion to the skin under the straps.
Choice D is wrong because the duration of treatment will be determined by your doctor and may vary.
Correct Answer is C
Explanation
Pad the side rails of the crib.
Padding the side rails of the crib can help prevent injury if the infant experiences seizures, which can be a symptom of bacterial meningitis.
Choice A is wrong because infants with bacterial meningitis may be sensitive to noise and light, so keeping the television on may not be appropriate.
Choice B is wrong because range of motion exercises to the neck and shoulders may not be appropriate for an infant with bacterial meningitis.
Choice D is wrong because placing the infant in a semiprivate room may increase the risk of infection 1.
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