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 D
Explanation
The nurse should prepare the toddler for nasotracheal intubation first because the toddler is experiencing severe dyspnea and drooling, which are signs of airway obstruction.
Nasotracheal intubation will help to secure the toddler’s airway and improve their breathing.
Choice A is wrong because administering an antibiotic is not the priority intervention for a toddler with airway obstruction.
Choice B is wrong because obtaining a blood culture is not the priority intervention for a toddler with airway obstruction.
Choice C is wrong because inserting an IV catheter is not the priority intervention for a toddler with airway obstruction.
Correct Answer is A
Explanation
An allergy to neomycin is a contraindication for receiving the MMR vaccine.
Choice Bis wrong because a family history of seizures is not a contraindication for receiving the MMR vaccine.
Choice Cis wrong because an upper respiratory infection 2 days ago is not a contraindication for receiving the MMR vaccine.
Choice Dis wrong because a temperature of 37.2°C (99°F) is not a contraindication for receiving the MMR vaccine.
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