A nurse is prioritizing care for four clients.
Which of the following clients should the nurse assess first?
adolescent who is in skin traction and reports pain level of 7 on a scale of 0 to 10
adolescent who has sickle cell anemia and slurred speech
toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus
toddler who has partial burn thickness burns on the right hand and requires a dressing change .
The Correct Answer is B
When prioritizing care for multiple clients, the nurse should first assess the client who is most unstable and has the most urgent needs. In this case, the adolescent with sickle cell anemia and slurred speech should be assessed first. Slurred speech could indicate a stroke, which is a life-threatening condition that requires immediate medical attention. The other clients, while they also require care, are not in immediate danger and can be assessed after the adolescent with sickle cell anemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C.
Choice A reason: A White Blood Cell (WBC) count of 20,000/mm³ is significantly higher than the normal range for children, which is typically between 5,000 to 10,000/mm³. In the context of acute lymphoblastic leukemia (ALL), a high WBC count could indicate an active disease process or a reaction to treatment, rather than a therapeutic effect.
Choice B reason: A hemoglobin level of 5.5 g/dL is quite low, as the normal range for children is generally between 11 to 16 g/dL. This level of hemoglobin suggests anemia, which is a common condition in patients with leukemia due to the disease itself or as a side effect of chemotherapy. It does not necessarily indicate that the treatment is having a therapeutic effect.
Choice C reason: A Platelet count of 150,000/mm³ is within the lower end of the normal range for children, which is approximately 150,000 to 450,000/mm³. This can be considered a sign that the treatment is working effectively, as it indicates bone marrow recovery and the production of platelets is returning to normal levels.
Choice D reason: A Red Blood Cell (RBC) count of 3/mm³ is extremely low. The normal range for children’s RBC count is about 4 million to 5.5 million/mm³. Such a low RBC count would indicate severe anemia and is not a sign of effective treatment for ALL.
Correct Answer is D
Explanation
Choice A rationale
Administering methylprednisolone, a corticosteroid, can help reduce inflammation. However, it is not the first-line treatment for severe anaphylaxis.
Choice B rationale
Administering oxygen can help improve the child’s oxygenation, but it is not the first action the nurse should take in this situation.
Choice C rationale
Administering a nebulized bronchodilator can help relieve wheezing, but it is not the first action the nurse should take in this situation.
Choice D rationale
Administering epinephrine is the first-line treatment for anaphylaxis. It works quickly to improve breathing, stimulate the heart, raise a dropping blood pressure, and reduce swelling of the face, lips, and throat.
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