The nurse receives shift report on four patients. Which patient will the nurse prioritize?

A 5-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hours ago.

A 3-year-old toddler who swallowed several sunflower seeds and continues to cough with an oxygen saturation of 91%.

A 15-year-old adolescent who had a laparoscopic appendectomy 10 hours ago, rates their pain a 3/10, and is preparing for discharge this morning.

An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hours and ate 70% of their meals.

Answer and Explanation

The Correct Answer is B

Choice A reason: While a child with asthma exacerbation needs monitoring, they used their rescue inhaler 16 hours ago and are currently stable. This patient is not the highest priority.

Choice B reason: A 3-year-old who continues to cough with an oxygen saturation of 91% is at risk of respiratory distress or obstruction due to the swallowed sunflower seeds. The low oxygen saturation indicates impaired gas exchange and requires immediate attention.

Choice C reason: A 15-year-old recovering from a laparoscopic appendectomy who is stable and preparing for discharge can wait to be seen after more urgent cases.

Choice D reason: An 18-month-old admitted for dehydration who is producing a normal number of wet diapers and eating well indicates improved hydration status and can be seen after addressing the more critical situation.

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Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason: The designation T3 indicates that the patient has had three full-term births, defined as births that occurred between 37 and 42 weeks of gestation. This is part of the standard obstetric history notation.

Choice B reason: The notation P1 means the patient has had one preterm birth, which is defined as a birth that occurred between 20 weeks and 36 weeks 6 days of gestation. This is an important part of understanding the patient's pregnancy history.

Choice C reason: A2 denotes that the patient has had two pregnancy losses before 20 weeks of gestation, which can include miscarriages or stillbirths. This is crucial for assessing the patient's reproductive health history.

Choice D reason: There is no indication from the notation G6, T3, P1, A2, L4 that the patient has had three elective abortions. Elective abortions would be noted differently in the patient's chart if they were part of the obstetric history.

Choice E reason: The notation L4 indicates that the patient currently has four living children. This is an important part of the patient's obstetric history as it gives insight into their childbearing outcomes.

A. Ibuprofen. B. Vigorous massage. C. Cold compress. D. Formula supplements. E. Lactation consult.

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help relieve pain and reduce inflammation associated with cracked nipples and engorged breasts. It is commonly used to manage postpartum pain and can provide significant relief, making breastfeeding more comfortable for the patient.

Choice B reason: Vigorous massage is not recommended for engorged breasts as it can cause additional pain and may worsen the condition. Gentle massage may help in some cases, but vigorous massage can lead to tissue damage and further discomfort. The focus should be on gentle techniques to manage engorgement.

Choice C reason: Cold compresses are effective in reducing swelling and providing pain relief for engorged breasts. Applying cold packs to the breasts can help reduce inflammation and soothe discomfort, making it easier for the patient to breastfeed. Cold therapy is a simple and non-invasive method to manage engorgement and related symptoms.

Choice D reason: Formula supplements are generally not recommended as a first-line intervention for breastfeeding issues, especially when the goal is to promote exclusive breastfeeding. Introducing formula can interfere with milk supply and the breastfeeding process. Instead, addressing the underlying issues such as latch and nipple care is more appropriate.

Choice E reason: A lactation consult is an essential intervention for a patient experiencing breastfeeding difficulties. Lactation consultants are trained to provide support and guidance on breastfeeding techniques, including how to achieve a proper latch, manage engorgement, and care for cracked nipples. Their expertise can significantly improve the breastfeeding experience and help resolve common issues.

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The nurse receives shift report on four patients. Which patient will the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the chart of a patient on the postpartum unit. The chart indicates the patient is a G6, T3, P1, A2, L4. What is the nurse's interpretation of this patient's obstetric history? Select All That Apply

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is caring for a patient three days postpartum who is exclusively breastfeeding. Upon assessment, the patient has cracked nipples, engorged breasts, and a painful latch. What will the nurse include in the patient's plan of care? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

The nurse is teaching a parent who delivered the baby with vacuum-assisted delivery. Which of the following statements will confirm to the nurse that the teaching was effective?

The nurse is caring for a 13-year-old diagnosed with atrial septal defect (ASD). Their caregivers report that the child seems more anxious and worried than usual. Considering the diagnosis of ASD, which of the following responses is appropriate for the nurse to make?

A nurse is caring for a full-term newborn diagnosed with persistent/patent ductus arteriosus (PDA). The newborn's caregiver asks the nurse, "What causes a PDA?" How will the nurse answer this question?

The nurse is caring for a child who is diagnosed with severe dehydration and is being treated with intravenous fluids. The nurse notes bilateral crackles on lung auscultation. Which actions will the nurse prioritize?

The nurse is educating a caregiver about infant feeding. Which statement by the caregiver demonstrates an understanding of the teaching?

The nurse is teaching parents of a newborn recently diagnosed with sickle cell anaemia. Which interventions will the nurse include in the education? Select all that apply.

The nursing student is creating a plan of care for a patient with a complex medical history. Which discharge intervention will require further education by the nursing instructor?

The nurse is providing care to an infant with sickle cell anaemia who has increased work of breathing, a fever, coarse crackles upon auscultation, oxygen saturation of 89%, and inconsolable crying. Which intervention will the nurse perform first?