A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions

A 3-year-old child who has an atrial septal defect and a heart rate of 120/min

A 5-year-old child who has type 1 diabetes mellitus and a blood sugar of 150 mg/dL

A 2-year-old child who has diarrhea and reports abdominal pain

Answer and Explanation

The Correct Answer is A

A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.

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Correct Answer is C

Explanation

A. Feeling pulsations in the neck is not an expected sensation during electroconvulsive therapy (ECT). The client is under general anesthesia and does not feel the procedure.
B. The client typically wakes up within 5 to 10 minutes after ECT, though they may remain drowsy for a while. 30 minutes is too long for initial awakening.
C. Post-procedure confusion and memory loss are common and temporary side effects of ECT, lasting a few hours to days in some cases.
D. Voice changes are not associated with ECT. The procedure does not affect the vocal cords or speech.

A. Client rates pain with contractions as a 3 on a scale of 0 to 10 B. FHR 150/min with moderate variability. Accelerations present, no decelerations noted C. Heart rate 88/min D. Respiratory rate 16/min E. Blood pressure 122/80 mm Hg F. Oxygen saturation 98% on room air

Correct Answer is ["A","B","C","D","E"]

Explanation

Heart rate decreased from 104/min to 88/min, indicating improved hemodynamic stability.
Respiratory rate decreased from 20/min to 16/min, suggesting relaxation and reduced distress.
Blood pressure slightly decreased from 132/84 mm Hg to 122/80 mm Hg, indicating improved comfort and reduced pain-related stress response.
Pain level decreased to 3/10 after epidural placement, demonstrating effective pain management.
FHR 150/min with moderate variability and accelerations present, no decelerations, indicating fetal well-being.

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A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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