A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?

A child who has acute epiglottitis and is drooling

A child who has mononucleosis and reports severe fatigue

A child who has Wilms' tumor and an abdominal mass

A child who has a urinary tract infection and bright red blood in their urine

Answer and Explanation

The Correct Answer is A

A. A child who has acute epiglottitis and is drooling: Acute epiglottitis is a medical emergency that can rapidly progress to airway obstruction and respiratory distress. Drooling is a significant sign of airway compromise in children with epiglottitis due to swelling of the epiglottis. This child requires immediate assessment and intervention to ensure airway patency.
B. A child who has mononucleosis and reports severe fatigue: While mononucleosis can cause severe fatigue, it is not an immediate life-threatening condition compared to acute epiglottitis. Assessment and intervention for severe fatigue can be prioritized after addressing the child with potential airway compromise.
C. A child who has Wilms' tumor and an abdominal mass: Wilms' tumor is a type of kidney cancer that typically presents with an abdominal mass. While it requires timely medical intervention, it is not as urgent as acute epiglottitis, which poses a risk of airway obstruction.
D. A child who has a urinary tract infection and bright red blood in their urine: While a urinary tract infection with hematuria requires assessment and treatment, it is not immediately life-threatening compared to acute epiglottitis. Addressing the child with potential airway compromise takes precedence over evaluating and managing hematuria.

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Correct Answer is C

Explanation

A. Initiate IV access on the palmar side of the client's wrist. - This option is not recommended because veins on the palmar side of the wrist are smaller and more prone to infiltration and nerve damage. The dorsal aspect of the hand or forearm is typically preferred for peripheral IV access due to larger veins and decreased risk of complications.
B. Choose the client's dominant arm for IV access whenever possible. - While it may be convenient to select the dominant arm for IV access, it is not always the best choice. Factors such as previous venipunctures, condition of veins, and patient comfort should be considered when selecting the site for IV insertion.
C. Select a site proximal to previous venipuncture sites. - This is the correct action. Choosing a site proximal (above) to previous venipuncture sites helps preserve veins and reduces the risk of venous sclerosis or phlebitis. It allows for better vein integrity and decreases the likelihood of complications associated with repeated punctures in the same area.
D. Insert a larger gauge IV catheter to prevent phlebitis. - Inserting a larger gauge IV catheter is not necessary to prevent phlebitis. In fact, using a larger gauge catheter may increase the risk of phlebitis and other complications. The appropriate gauge of the catheter depends on the client's condition, the type of fluids or medications to be administered, and the condition of the veins.

A. The client's heart rate increases by 10/min. B. The client's systolic blood pressure decreases by 25 mm Hg. C. The client's diastolic blood pressure increases by 10 mm Hg. D. The client reports heart palpitations.

Correct Answer is B

Explanation

A. The client's heart rate increases by 10/min: An increase in heart rate upon changing positions may occur as a compensatory mechanism to maintain blood pressure, but it is not indicative of orthostatic hypotension. Orthostatic hypotension is characterized by a decrease in blood pressure upon assuming an upright position.
B. The client's systolic blood pressure decreases by 25 mm Hg: Orthostatic hypotension is defined as a decrease in systolic blood pressure of 20 mm Hg or more, or a decrease in diastolic blood pressure of 10 mm Hg or more, within 3 minutes of standing up from a supine position. Therefore, a decrease in systolic blood pressure by 25 mm Hg upon changing positions is consistent with orthostatic hypotension.
C. The client's diastolic blood pressure increases by 10 mm Hg: Orthostatic hypotension typically involves a decrease in both systolic and diastolic blood pressure upon assuming an upright position. An increase in diastolic blood pressure is not consistent with orthostatic hypotension.
D. The client reports heart palpitations: Heart palpitations may occur due to various reasons, such as anxiety or cardiac arrhythmias, but they are not specific to orthostatic hypotension. While orthostatic hypotension may cause symptoms like dizziness or lightheadedness, heart palpitations are not typically associated with this condition.

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A nurse is caring for four children in an emergency department. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is inserting a short peripheral IV catheter for a client who requires IV fluids. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

Correct Answer is B

Explanation

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