A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
An infant who has pertussis and is receiving oxygen via nasal cannula.
A school-age child who has diabetes mellitus and requires blood glucose monitoring.
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
A toddler who has both arms in casts and needs to be fed his breakfast.
The Correct Answer is A
Choice A reason:
An infant who has pertussis and is receiving oxygen via nasal cannula: Pertussis, also known as whooping cough, is a highly contagious respiratory disease that can be particularly severe in infants. The fact that the infant is receiving oxygen indicates respiratory distress, which is a critical condition requiring immediate attention. Infants with pertussis are at high risk for complications such as pneumonia, apnea, and respiratory failure. Therefore, this patient should be assessed first to ensure their airway and breathing are adequately supported.
Choice B reason:
A school-age child who has diabetes mellitus and requires blood glucose monitoring: While it is important to monitor blood glucose levels in children with diabetes mellitus to prevent hypo- or hyperglycemia, this condition is generally more stable and manageable compared to the acute respiratory distress seen in the infant with pertussis. Blood glucose monitoring can be scheduled and managed, making it a lower priority in this context.
Choice C reason:
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions: Sickle cell crisis can be extremely painful and requires careful management. However, if the adolescent is ready for discharge, it indicates that their condition has stabilized. Providing discharge instructions is important but can be deferred until more critical patients are assessed.
Choice D reason:
A toddler who has both arms in casts and needs to be fed his breakfast: While this toddler requires assistance with feeding due to their casts, this situation does not pose an immediate threat to their health. Feeding can be managed after ensuring that more critical patients, such as the infant with pertussis, are stable.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Restricting the client’s oral fluid intake is not appropriate in this situation. Adequate fluid intake is essential to help flush out the bladder and prevent clot formation. Clients are usually encouraged to drink plenty of fluids to ensure proper hydration and urine flow.
Choice B reason:
Reminding the client that he might feel a constant urge to void is important. After a transurethral resection of the prostate (TURP), the presence of the catheter and continuous bladder irrigation can cause a sensation of needing to urinate. This is a common experience and reassuring the client helps manage their expectations and reduce anxiety.
Choice C reason:
Weighing the client every evening is not a standard intervention specifically related to TURP and continuous bladder irrigation. While monitoring weight can be important for overall health, it is not directly related to the immediate postoperative care of a TURP patient.
Choice D reason:
Monitoring the client’s urine output every 6 hours is important, but it should be done more frequently in the immediate postoperative period. Continuous bladder irrigation requires close monitoring to ensure that the irrigation fluid is flowing properly and that there are no blockages or complications.
Correct Answer is A
Explanation
Choice A reason: Office of Emergency Management (OEM)
The Office of Emergency Management (OEM) is typically the first agency to be notified in the event of a nonbiological or chemical incident. The OEM coordinates the local response efforts and ensures that all necessary resources and personnel are mobilized. They work closely with other local, state, and federal agencies to manage the incident effectively. The OEM’s role includes assessing the situation, providing information to the public, and coordinating evacuation or shelter-in-place orders if necessary.
Choice B reason: Federal Emergency Management Agency (FEMA)
The Federal Emergency Management Agency (FEMA) plays a crucial role in disaster response and recovery at the federal level. However, they are usually involved after the initial local response has been established. FEMA provides support and resources to local and state agencies, but the immediate notification should go to the local Office of Emergency Management.
Choice C reason: American Red Cross (ARC)
The American Red Cross (ARC) is a vital organization in disaster response, providing emergency shelter, food, and medical care. While they are an essential part of the response team, they are not typically the first agency to be notified. The ARC works in coordination with local emergency management agencies to support the affected community.
Choice D reason: U.S. Department of Homeland Security (DHS)
The U.S. Department of Homeland Security (DHS) oversees national efforts to protect against and respond to various threats, including chemical incidents. However, like FEMA, DHS is generally involved at a higher level of coordination and support. The immediate response is managed by local agencies, with DHS providing additional resources and expertise as needed
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