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.

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Correct Answer is B,C,A,D

Explanation

A. Evaluate the UAP for signs of improvement: Following the teaching and feedback, the PN should observe the UAP’s future care interactions to ensure that the behavior has improved and that client privacy is consistently maintained.

B. Cover the client to provide privacy during care: The first priority is to protect the client’s dignity and privacy immediately. Ensuring the client is covered prevents further embarrassment and maintains ethical nursing standards.

C. Discuss the issue privately with the UAP: After addressing the client’s immediate needs, the PN should privately discuss the observed behavior with the UAP to promote learning and prevent public criticism, which can be unprofessional and counterproductive.

D. Report patterns of behavior to the supervisor: If the UAP repeatedly fails to uphold privacy standards despite feedback and monitoring, the PN must report the ongoing issue to the supervisor for further evaluation and possible corrective action.

A. Hematuria B. Polydipsia C. A sore throat D. Weight loss

Correct Answer is A

Explanation

Rationale:

A. Hematuria: Hematuria, often described by parents as cola- or tea-colored urine, is the hallmark sign of acute glomerulonephritis. It results from glomerular inflammation that allows red blood cells to leak into the urine. This visible change in urine color commonly prompts parents to seek medical attention.

B. Polydipsia: Increased thirst is more typical of diabetes mellitus or diabetes insipidus, not glomerulonephritis. Children with glomerulonephritis usually experience fluid retention rather than excessive thirst due to reduced kidney filtration and sodium retention.

C. A sore throat: A sore throat often precedes acute glomerulonephritis because the infection is commonly caused by group A beta-hemolytic Streptococcus. However, by the time glomerulonephritis develops, the sore throat has usually resolved, so it is not the primary reason parents seek care.

D. Weight loss: Weight loss is not typical of acute glomerulonephritis; instead, children often present with weight gain from fluid retention. The sudden presence of dark urine and swelling are more likely to alert parents to a kidney problem.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Upon entering a client's room, the practical nurse (PN) observes that the unlicensed assistive personnel (UAP) is providing personal care safely but exposing the client unnecessarily. In which order should the PN implement these interventions? (Rank the actions from first on top to last on bottom.)

Correct Answer is B,C,A,D

Explanation

The parents of a child with acute glomerulonephritis are describing to the practical nurse (PN) what originally motivated them to seek medical care. Which sign is the child most likely to have exhibited?

Correct Answer is A

Explanation

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Which task could the practical nurse (PN) safely delegate to the unlicensed assistive personnel (UAP)?

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