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 D
Explanation
Choice A rationale
Polyuria, or excessive urination, is not a typical symptom of acute acetylsalicylic acid poisoning.
Choice B rationale
Neck vein distension is not a typical symptom of acute acetylsalicylic acid poisoning.
Choice C rationale
Jaundice, or yellowing of the skin and eyes, is not a typical symptom of acute acetylsalicylic acid poisoning.
Choice D rationale
Hyperpyrexia, or extremely high fever, can be a symptom of severe acute acetylsalicylic acid poisoning.
Correct Answer is ["A","C","E"]
Explanation
Choice A rationale
Providing a high-calorie diet is a recommended action for a child who has received partial-thickness burns to
over 50% of his body. After a burn injury, the body needs extra calories and protein to heal, fight infection, and maintain its functions. A high-calorie diet can help meet these increased nutritional needs.
Choice B rationale
Administering analgesics intramuscularly (IM) is not a recommended action for a child with partial- thickness burns. Pain management is crucial in burn care, but analgesics should be given orally or intravenously, not IM, to avoid additional pain and tissue damage.
Choice C rationale
Monitoring intake and output is a recommended action for a child who has received partial-thickness burns to over 50% of his body. This can help assess the child’s hydration status, kidney function, and response to fluid replacement therapy.
Choice D rationale
Removing splints during sleep is not a recommended action for a child with partial-thickness burns. Splints are used to prevent contractures by keeping the joints in a functional position. They should be worn as prescribed by the healthcare provider, which often includes during sleep.
Choice E rationale
Changing dressings using aseptic technique is a recommended action for a child who has received partial- thickness burns to over 50% of his body. This can help prevent infection, promote healing, and assess the burn’s progress.
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