The pediatric nurse received report and will be caring for four patients. The nurse prioritizes care and chooses to assess which patient first?
Patient 1 is a 6-year-old with oral lesions from varicella (chicken pox) who is receiving IV fluids due to poor oral intake
Patient 2 is a 14-month-old admitted for meningitis on day 5 out of 10 for IV antibiotics
Patient 3 A 6-month-old with hypoplastic left heart syndrome 5 days after a Glenn procedure. This was the 2nd of 3 planned cardiac surgeries. Vitals were reported to be pulse 110, respiratory rate 30, BP 88/56, oxygen saturation 85%
Patient 4 A 3-year-old admitted for Kawasaki Disease 5 days ago. Temperature has been normal for past 24 hours. Child began complaining of chest pain an hour ago and pulse has increased from 108 to 145 at rest.
The Correct Answer is C
Rationale:
A. Patient 1 – 6-year-old with oral lesions from varicella receiving IV fluids: While poor oral intake requires monitoring and IV fluid support, the child’s vital signs and overall status do not indicate immediate life-threatening risk. Assessment is important but not the highest priority.
B. Patient 2 – 14-month-old with meningitis on day 5 of IV antibiotics: This patient is stable mid-course in treatment, showing no acute changes. Ongoing monitoring is necessary, but there are no current signs of decompensation requiring immediate attention.
C. Patient 3 – 6-month-old with hypoplastic left heart syndrome 5 days post-Glenn procedure, O₂ saturation 85%: Low oxygen saturation post-cardiac surgery is a critical finding indicating hypoxemia, which can quickly lead to deterioration. Assessing this patient first is essential to prevent respiratory or cardiac compromise.
D. Patient 4 – 3-year-old with Kawasaki Disease experiencing chest pain and increased pulse: Chest pain and tachycardia are concerning and require prompt evaluation; however, the post-operative cardiac patient with hypoxemia (Patient 3) has an immediate threat to life, making them the highest priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Elevated systolic blood pressure in the upper extremities and elevated systolic blood pressure in the lower extremities: Uniformly elevated blood pressure in both upper and lower extremities does not indicate coarctation of the aorta. This pattern may suggest systemic hypertension but not a localized obstruction of the aorta.
B. Elevated systolic blood pressure in the upper extremities and low systolic blood pressure in the lower extremities: This is characteristic of coarctation of the aorta, where narrowing of the aortic arch causes obstruction to blood flow to the lower extremities. The upper extremities receive blood before the narrowing, resulting in higher pressures compared with the legs.
C. Low systolic blood pressure in the upper extremities and low systolic blood pressure in the lower extremities: Low pressures in all extremities suggest generalized hypotension or poor cardiac output rather than a localized structural defect like coarctation of the aorta.
D. Low systolic blood pressure in the upper extremities and elevated systolic blood pressure in the lower extremities: This pattern is not consistent with coarctation of the aorta. Elevated lower extremity pressure with low upper extremity pressure may indicate other rare circulatory anomalies but is not typical for this condition.
Correct Answer is A
Explanation
Rationale:
A. A 3-year-old child who has experienced gross motor regression for six months: Persistent loss of previously acquired gross motor skills over an extended period is concerning and may indicate an underlying neurological, muscular, or developmental disorder. This type of regression warrants immediate further evaluation by a healthcare provider.
B. A 1-year-old child who has been waking frequently during the night crying after moving to a new house one week ago: Short-term sleep disturbances related to environmental changes are common in infants and usually resolve as the child adapts. This type of regression is temporary and not immediately concerning.
C. A 2-year-old child who has been experiencing regression for two weeks after beginning to attend day care: Brief behavioral or developmental regression due to adjustment stress is common in toddlers starting day care. This regression is short-lived and resolves with adaptation.
D. A 2-year-old child who has been hospitalized for cellulitis and is having incontinence resulting in diaper use: Regression in toileting during hospitalization is often a stress response and temporary. It usually resolves once the child returns to a familiar environment and is not indicative of a serious underlying condition.
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