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 B

Explanation

Choice A reason: Offering a snack and administering another dose is not appropriate, as it could lead to an overdose if any amount of the medication has been absorbed.

Choice B reason: Contacting the healthcare provider is the safest action. The provider can give specific instructions on how to proceed, including whether another dose should be given and when.

Choice C reason: Immediately administering another dose is not advisable, as it could lead to an overdose if any amount of the medication has been absorbed.

Choice D reason: Holding the next dose without consulting the healthcare provider might result in the child not receiving the necessary medication. Always follow the healthcare provider's instructions.

A. My child does not need Factor VIII before a dental cleaning. B. It is okay to use aspirin if my child is in pain or has a fever. C. There are no limitations on the type of activities my child can do. D. Swimming is an appropriate activity for my child.

Correct Answer is D

Explanation

Choice A reason: Haemophilia patients often require Factor VIII replacement therapy before procedures such as dental cleanings to prevent bleeding. The statement that the child does not need Factor VIII before a dental cleaning indicates a misunderstanding of the need for prophylactic treatment.

Choice B reason: Aspirin is contraindicated for children with haemophilia as it can inhibit platelet function and increase the risk of bleeding. The statement that it is okay to use aspirin reflects a lack of understanding of the appropriate pain management for haemophilia.

Choice C reason: While it is important for children with haemophilia to stay active, certain high-impact or contact sports may increase the risk of bleeding and should be avoided. The statement that there are no limitations on the type of activities indicates a lack of awareness about the need to choose safe activities.

Choice D reason: Swimming is a low-impact activity that is generally safe and beneficial for children with haemophilia. It promotes cardiovascular fitness and muscle strength without putting undue stress on the joints or increasing the risk of bleeding. This statement demonstrates an understanding of appropriate activity choices for a child with haemophilia.

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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

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Correct Answer is D

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