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
A weight loss of 7% indicates that the infant is moderately dehydrated.
Dehydration is classified as mild (3-5% weight loss), moderate (6-10% weight loss), or severe (>10% weight loss)1.
Choice A is wrong because a respiratory rate of 28/min is within the normal range for an infant.
Choice B is wrong because a capillary refill time of 1 second is within the normal range.
Choice D is wrong because bradycardia (a slow heart rate) is not a typical sign of moderate dehydration in infants.
Correct Answer is A
Explanation
Choice A: Gentamicin is an aminoglycoside antibiotic that can cause nephrotoxicity. Nephrotoxicity refers to kidney damage and can be demonstrated by rising serum creatinine levels. A creatinine level of 1.4 mg/dL is higher than the normal range and may indicate impaired kidney function 2.
Choice B is wrong because Creatinine 0.3 mg/dL is not an answer because it falls within the normal range for creatinine levels.
Choice C is wrong because BUN 12 mg/dL is not an answer because it falls within the normal range for BUN levels.
Choice D is wrong because BUN 6 mg/dL is not an answer because it falls within the normal range for BUN levels.
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