A nurse is assisting with the care of a group of pediatric clients. Which of the following actions should the nurse take first?
Deliver a breakfast tray to a child who has been administered regular insulin.
Complete pin site care for a child who is in skeletal traction.
Provide clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy.
Administer acetaminophen to a child who has a temperature of 101.2°F (38.4°C).
The Correct Answer is A
If a nurse is assisting with the care of a group of pediatric clients, the first action the nurse should take is to deliver a breakfast tray to a child who has been administered regular insulin. This is because regular insulin is a fast-acting insulin that begins to lower blood sugar levels within 15 minutes of administration. It is important for the child to eat shortly after receiving regular insulin to prevent hypoglycemia.
Option B is incorrect because completing pin site care for a child who is in skeletal traction is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option C is incorrect because providing clear liquids to a child who is 4 hr postoperative following a laparoscopic appendectomy is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
Option D is incorrect because administering acetaminophen to a child who has a temperature of 101.2°F (38.4°C) is not as time-sensitive as delivering a breakfast tray to a child who has been administered regular insulin.
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Related Questions
Correct Answer is B
Explanation
A nurse's best protection against negligence or malpractice is to follow the standards of practice. These standards define the acceptable level of care that a nurse is expected to provide and are based on current evidence and professional consensus. By adhering to these standards, a nurse can demonstrate that they have provided care that meets the expected level of quality and safety.
The other options are not the best protection against negligence or malpractice. Asking permission from the managing nurse prior to performing any duties [a] may be helpful in some situations, but it is not a guarantee against negligence or malpractice. Never being alone with a patient [c] is not practical or necessary for providing safe and effective care. Recording patient interactions with your phone [d] may violate patient privacy and is not an effective way to prevent negligence or malpractice.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale: A client who had a blood transfusion and has a blood pressure of 138/76 mm Hg. This client is stable. The blood pressure is within normal range, indicating that the client is not experiencing a transfusion reaction, which could cause hypotension. Therefore, this client is not the highest priority.
Choice B rationale: A client who has skeletal traction for a femur fracture and reports incisional discomfort of 4 on a scale of 0 to 10. While pain management is an important aspect of client care, a pain level of 4 indicates that the client’s pain is manageable. Therefore, this client is not the highest priority.
Choice C rationale: A client who is 4 hours postoperative following a total hip arthroplasty and has a urinary output of 15 mL/hr. This client is showing signs of oliguria, which could indicate a serious complication such as hypovolemia or acute kidney injury. This client is the highest priority because these complications can lead to further serious issues such as shock or end-organ damage if not addressed promptly.
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