A nurse on a pediatric unit is receiving a report from an assistive personnel (AP). Which of the following clients should the nurse plan to visit first?
A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%
A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F)
A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002
A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale
The Correct Answer is C
A. A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%. While status asthmaticus is a serious condition, a pulse oximetry reading of 95% indicates adequate oxygenation, so this child is not in immediate distress.
B. A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F). While the fever requires monitoring and treatment, roseola is typically a self-limiting illness, and this temperature, while high, is not immediately life-threatening.
C. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002. A urine specific gravity of 1.002 indicates very dilute urine, which is concerning for diabetes insipidus and potential dehydration. This condition requires immediate attention to prevent severe dehydration and electrolyte imbalance.
D. A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale. While managing pain in sickle cell anemia is important, the child’s condition is stable, and pain relief can be addressed after assessing the more urgent case of potential dehydration in the child with diabetes insipidus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Maintain medical asepsis during dressing changes: While cleanliness is important, aseptic (sterile) technique is typically required for burn care to prevent infection.
B. Administer pain medication 30 min to 1 hour before physical therapy: Pain management is crucial to facilitate participation in physical therapy and improve outcomes.
C. Allow the child to set her own schedule for care: A structured schedule is necessary to ensure regular treatment and care for burns.
D. Provide low-calorie snacks: High-calorie, protein-rich foods are necessary to meet increased metabolic demands for healing.
Correct Answer is C
Explanation
A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.
B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.
C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.
A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.
B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.
C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.
A. Firmly push a cotton ball into the ear canal after instilling drops. Firmly pushing a cotton ball into the ear canal is not recommended as it can cause irritation or damage to the ear canal. A loose cotton ball can be placed at the entrance of the ear canal to prevent the drops from leaking out, but it should not be inserted deeply.
B. Pull the child's ear auricle upward and outward just before instilling drops. For a child under 3 years old, the ear auricle should be pulled downward and backward to straighten the ear canal for proper administration of ear drops. Pulling upward and outward is appropriate for older children and adults.
C. Apply clean gloves and clean the outer ear prior to instilling drops. Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
D. Warm the medication container for 10 seconds in a microwave oven prior to installation. Microwaving medication is not recommended as it can overheat and degrade the medication. Warming the drops by holding the container in your hands for a few minutes is safer and helps to avoid the discomfort of cold drops.
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