A nurse is prioritizing care for four clients.
Which of the following clients should the nurse assess first?
An adolescent who has sickle cell anemia and slurred speech.
An adolescent who is in skin traction and reports a pain level of 7 on a scale from 0 to 10.
A toddler who has a new diagnosis of osteomyelitis and is to receive an IV bolus of nafcillin.
A toddler who has a partial-thickness burn on his right hand and requires a dressing change.
The Correct Answer is A
An adolescent who has sickle cell anemia and slurred speech should be assessed first.
Slurred speech can be a sign of a stroke, which is a known complication of sickle cell anemia.
This requires immediate medical attention.
Choice B is wrong because while pain management is important, it is not as urgent as a potential stroke.
Choice C is wrong because while administering medication is important, it is not as urgent as a potential stroke.
Choice D is wrong because while wound care is important, it is not as urgent as a potential stroke.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Elevate the infant’s head to a 10° angle during feedings.
This position can help prevent milk from coming out of the infant’s nose and reduce the risk of choking.
Choice A is wrong because watery eyes are not an indication to discontinue feeding.
Choice B is wrong because babies with cleft palate should be burped more frequently, but not so often as to interrupt good feeding behaviors.
Choice D is wrong because the amount of formula an infant needs varies and should be determined by a pediatrician.
Correct Answer is C
Explanation
During a seizure, it is important to clear the area around the person of anything hard or sharp to prevent injury.
Choice A is wrong because Minimize movement of the limbs, is not a recommended action during a seizure as it is important not to hold the person down or try to stop their movements.
Choice B is wrong because Insert a tongue blade between the teeth, is not a recommended action during a seizure as it is important not to put anything in the person’s mouth.
Choice D is wrong because Place the child in a prone position, is not a recommended action during a seizure as it is important to turn the person gently onto one side to help them breathe.
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