A nurse on a pediatric unit is receiving a change of shift report for a group of clients. Which of the following clients should the nurse see first?
A child who is postoperative following a tonsillectomy and reports moderate throat pain.
A child who had a cardiac catheterization using the femoral artery and has blanching of the toes
A child who has bacterial pneumonia and is due for their initial dose of IV antibiotics.
A child who has juvenile idiopathic arthritis and needs assistance with application of prescribed splints.
The Correct Answer is B
A. A child who is postoperative following a tonsillectomy and reports moderate throat pain:
Pain is expected post-tonsillectomy and, while it should be managed, it is not immediately life-threatening.
B. A child who had a cardiac catheterization using the femoral artery and has blanching of the toes.
Blanching suggests compromised blood flow, which is a vascular emergency and must be addressed immediately.
C. A child who has bacterial pneumonia and is due for their initial dose of IV antibiotics:
Timely administration is important, but compromised circulation (choice B) takes priority.
D. A child who has juvenile idiopathic arthritis and needs assistance with application of prescribed splints:
Assisting with splints is not urgent compared to vascular compromise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Expect the medication to cause constipation for the first few days of therapy."
Metformin more commonly causes diarrhea, nausea, and abdominal discomfort, not constipation.
B. "Take the medication at the same time each day."
Consistent dosing helps maintain stable blood glucose levels. Metformin is usually taken once or twice daily with meals.
C. "This medication is used for short-term therapy until your symptoms improve."
Type 2 diabetes is a chronic condition. Metformin is often used as a long-term maintenance therapy.
D. "Take this medication 1 hour before meals."
Metformin should be taken with meals to reduce gastrointestinal side effects, not on an empty stomach.
Correct Answer is B
Explanation
A. The infant does not exhibit fear of strangers:
Stranger anxiety typically develops around 6–8 months, so not showing it at exactly 6 months is not immediately concerning.
B. The infant does not roll over from their abdomen to their back:
By 6 months, an infant should be able to roll over. Failure to achieve this milestone suggests a delay in gross motor development and needs evaluation.
C. The infant does not pick up objects from the floor with their fingers:
Fine motor skills such as using fingers to pick up small objects (pincer grasp) develop around 8–9 months.
D. The infant does not sit on the floor unsupported:
Sitting unsupported typically develops between 6–8 months. At 6 months, it may not be fully achieved yet, so it’s not necessarily abnormal.
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