A nurse in an urgent care clinic is prioritizing care for four children. Which of the following children should the nurse assess first?
A toddler who has nephrotic syndrome and facial edema.
An adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lb).
A preschool-age child who has a muffled voice and no spontaneous cough.
A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL.
The Correct Answer is C
A preschool-age child who has a muffled voice and no spontaneous cough should be assessed first.
These symptoms may indicate epiglottitis, which is a life-threatening condition that requires immediate medical attention.

Choice A, B and D are also important but not as urgent as choice C. A toddler with nephrotic syndrome and facial edema, an adolescent with Crohn’s disease and recent weight loss, and a school-age child with diabetes mellitus and a blood glucose of 200 mg/dL should be assessed after the preschool-age child with a muffled voice and no spontaneous cough.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy.
This is because the child may be swallowing blood that is coming from the surgical site.
Choice A is wrong because a blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child.
Choice B is wrong because a heart rate of 54/min is within the normal range for a 5-year-old child.
Choice D is wrong because flushing of the face is not an indication of hemorrhage following a tonsillectomy and adenoidectomy.
Correct Answer is D
Explanation
Wearing a wide-brimmed hat can help protect a child’s face, neck and ears from the harmful effects of the sun.

Choice A is wrong because while staying under a beach umbrella can provide some protection from the sun, it is not enough on its own.
Choice B is wrong because loose-weave clothing may not provide enough protection from the sun’s rays.
Choice C is wrong because a sunscreen with an SPF of at least 30 is recommended for adequate protection.
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