The practical nurse (PN) is assigned to care for four children. Which child should be assessed first?

4 year-old who needs to stand to void before going to x-ray

3-year-old who is in isolation with chickenpox lesions and MRSA

18-month-old who has cystic fibrosis and is wheezing

2-year-old who is admitted for gastroenteritis and vomiting.

Answer and Explanation

The Correct Answer is C

A. 4-year-old who needs to stand to void before going to x-ray: This child requires assistance with a non-urgent procedure. While important for completing diagnostics, it is not an immediate threat to the child’s health or airway.

B. 3-year-old who is in isolation with chickenpox lesions and MRSA: Isolation precautions are important to prevent infection spread, but the child’s current condition is stable and does not indicate acute respiratory distress.

C. 18-month-old who has cystic fibrosis and is wheezing: Wheezing in a child with cystic fibrosis indicates potential airway obstruction or respiratory compromise, which can rapidly become life-threatening. This child requires immediate assessment and intervention to ensure airway patency and oxygenation.

D. 2-year-old who is admitted for gastroenteritis and vomiting: Gastroenteritis and vomiting require monitoring for dehydration, but unless there are signs of severe fluid loss or electrolyte imbalance, it is less urgent than a child experiencing respiratory distress.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Platelet count 135,000/mm³ or 135 x 10⁹/L: This mild thrombocytopenia is a common effect of chemotherapy and does not require urgent intervention unless the count drops below 100,000/mm³ or active bleeding occurs.

B. Blood urea nitrogen 75 mg/dL or 12.9 mmol/L: A BUN level this high indicates severe renal impairment or dehydration, both of which are critical in a chemotherapy patient. Renal dysfunction can result from nephrotoxic effects of chemotherapeutic drugs and must be reported immediately to prevent further kidney damage.

C. Decreased deep tendon reflexes: While this may suggest electrolyte imbalance or peripheral neuropathy, it is not immediately life-threatening and can be monitored until further evaluation.

D. Periodic nausea and vomiting: These are expected side effects of chemotherapy and, though uncomfortable, do not represent an acute or life-threatening condition compared to severe renal dysfunction reflected by the elevated BUN.

A. Measure blood pressure. B. Observe pressure areas. C. Notify the charge nurse. D. Apply a pulse oximeter.

Correct Answer is D

Explanation

A. Measure blood pressure: While assessing blood pressure provides useful data about cardiovascular status, it does not give immediate information about the client’s oxygenation level. The priority in dyspnea is to evaluate respiratory function before addressing circulatory parameters.

B. Observe pressure areas: Inspecting pressure areas is important for skin integrity in a bedfast client but is not an immediate concern when the client shows signs of respiratory distress. The focus should first be on assessing oxygen saturation and airway status.

C. Notify the charge nurse: Communication with the charge nurse is necessary, but only after the PN has obtained essential assessment data. Reporting findings such as oxygen saturation helps guide urgent interventions and escalation of care.

D. Apply a pulse oximeter: Applying a pulse oximeter is the first action because it provides rapid, objective information about the client’s oxygenation status. This allows the PN to determine the severity of hypoxia and respond promptly with appropriate interventions or reporting.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The practical nurse (PN) is assigned to care for four children. Which child should be assessed first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

While turning and positioning a bedfast client, the practical (PN) observes that the client is dyspneic. Which action should the PN take first?

Correct Answer is D

Explanation

The practical nurse (PN) administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the PN monitor? (Select all that apply.)

The practical nurse (PN) is assisting with screening examinations at a community clinic where a toddler is brought by a parent for scheduled vaccines. The toddler clings to the caregiver and cowers when approached. Which assessment warrants immediate intervention by the PN?

The practical nurse (PN) determines that a client who is one day postpartum has a moderate amount of lochia rubra and the uterus is firm, dextroverted, and three fingerbreadths above the umbilicus. Which should be the PN's initial action?

A client with heart failure (HF) is taking a diuretic to manage fluid retention. In evaluating the effectiveness of the medical regimen, which assessment is most important for the practical nurse (PN) to monitor?

A female client with immune thrombocytopenic purpura (ITP) is transferred to a long term care facility for physical rehabilitation. To prevent injury, which action is most important for the practical nurse to implement?

During a clinic visit, the practical nurse (PN) observes an infant sucking on a pacifier that is made from a bottle nipple and stuffed with cotton. What should the PN do?

The practical nurse (PN) learns in report that a client has jugular vein distention (JVD). Which technique should the PN use to confirm this finding?

A client is scheduled for a thoracentesis that will be done at the bedside. What should the practical nurse (PN) prepare before the healthcare provider arrives on the unit to perform the procedure?