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
Choice A rationale
Hyperactivity can be a normal behavior in preschoolers. It may or may not be related to the brain tumor.
Choice B rationale
Pruritus is not typically associated with a brain tumor. It could be related to other conditions or medications.
Choice C rationale
Diplopia, or double vision, can be a sign of increased intracranial pressure, which is a serious complication of a brain tumor. This should be reported to the provider immediately.
Choice D rationale
Nightmares are common in children and may not be directly related to the brain tumor. While they should be addressed, they are not the priority in this case.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Increased restlessness in a toddler with a full-thickness burn may indicate hypoxia, pain, or shock. These conditions require immediate medical attention to prevent further complications and ensure proper management of the burn injury.
Choice B rationale: A respiratory rate of 25/min is within the normal range for toddlers (20-30 breaths per minute). This finding does not indicate an immediate concern that requires reporting to the provider.
Choice C rationale: Bowel sounds of 20/min are within the normal range (5-30 sounds per minute). This finding does not indicate any gastrointestinal complications that need to be reported to the provider.
Choice D rationale: Urinary output of 35 mL/hr is within the normal range for toddlers (1-2 mL/kg/hr). This finding indicates adequate kidney function and hydration status, so it does not require immediate reporting.
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