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 D
Explanation
A. Keep the client's leg in a dependent position. Keeping the leg in a dependent position can increase swelling and delay healing. The leg should be elevated to reduce swelling and promote circulation.
B. Use a hair dryer on a hot setting to dry the cast. Using a hair dryer on a hot setting can cause burns and does not effectively dry a plaster cast. Plaster casts take time to dry and should be air-dried naturally.
C. Discourage the client from ambulating: Early mobilization is encouraged to prevent complications like muscle atrophy and joint stiffness, as long as it is safe and the healthcare provider has approved it. Completely discouraging ambulation is not generally recommended unless specified by a doctor.
D. Perform a neurovascular check of the lower extremities. Neurovascular checks are essential to ensure that there is adequate blood flow and nerve function below the cast. This includes checking for pain, pallor, pulse, paresthesia, and paralysis (the 5 P’s). This helps detect complications like compartment syndrome or decreased circulation early.
Correct Answer is B
Explanation
A. Capillary refill less than 2 seconds: A capillary refill time of less than 2 seconds indicates good peripheral circulation, which is normal and not a cause for concern in this context. It is not the priority.
B. Tingling in the right foot Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation, which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
C. 2+ right pedal pulse Rationale: A 2+ pedal pulse indicates a normal pulse strength, which suggests that there is adequate blood flow to the extremity. It is not a priority compared to the potential for neurological or circulatory compromise.
D. Respiratory rate 24/min Rationale: A respiratory rate of 24/min is within the normal range for a school-age child (18-30 breaths per minute). While it is important to monitor vital signs, it is not a priority concern related to the fracture.
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