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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "I'll give him acetaminophen for the pain.": Acetaminophen is used for pain relief and fever reduction but does not address disease transmission. It does not prevent the spread of the streptococcal infection.

B. "I'll discard his toothbrush and buy another.": This is crucial because the streptococcal bacteria can remain on the toothbrush, leading to potential reinfection or spreading the bacteria to others. Replacing the toothbrush after starting antibiotics helps to reduce the risk of reinfection.

C. "I'll continue to encourage him to drink lots of fluids.": Staying hydrated is important for recovery, but it does not prevent the transmission of the infection.

D. "I'll take his temperature every 4 hours.": Monitoring temperature helps track the child’s condition but does not prevent the spread of the infection.

A. Rotavirus B. Measles, mumps, rubella (MMR) C. Varicella (VAR) D. Influenza

Correct Answer is A

Explanation

A. Rotavirus: The rotavirus vaccine is recommended for infants at 2, 4, and possibly 6 months of age, depending on the vaccine formulation. It helps protect against rotavirus, which can cause severe diarrhea and dehydration in infants.

B. Measles, mumps, rubella (MMR): The MMR vaccine is not given until 12-15 months of age. It is not part of the vaccination schedule for a 4-month-old infant.

C. Varicella (VAR): The varicella vaccine is typically administered at 12-15 months of age. It is not appropriate for a 4-month-old infant.

D. Influenza: The influenza vaccine is recommended annually starting at 6 months of age. A 4-month-old is too young to receive the influenza vaccine.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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