A nurse is reviewing data for patients on an inpatient unit. Which patient will the nurse see first?
A 6-year-old who has asthma and an oxygen saturation of 94% on room air.
A 10-year-old who has sickle cell anaemia reporting severe chest pain.
A 47-year-old who has diabetes insipidus with a urine specific gravity of 1.010.
A 5-year-old who has respiratory syncytial virus (RSV) with a temperature of 102.2°F.
The Correct Answer is B
Choice A reason: While an oxygen saturation of 94% is slightly low, it is not an immediate emergency for a child with asthma. This patient can be monitored but does not require the nurse's immediate attention.
Choice B reason: Severe chest pain in a patient with sickle cell anaemia can indicate a serious complication known as acute chest syndrome, which is a medical emergency. This condition requires immediate assessment and intervention to prevent life-threatening complications.
Choice C reason: A urine specific gravity of 1.010 indicates dilute urine, which is typical for a patient with diabetes insipidus. While this condition requires management, it is not an immediate emergency compared to severe chest pain in a sickle cell anaemia patient.
Choice D reason: A fever of 102.2°F in a child with respiratory syncytial virus (RSV) is concerning and requires attention, but it is not as immediately life-threatening as severe chest pain in a sickle cell anaemia patient. This patient can be seen after addressing the more urgent case.
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Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A reason: Facilitating an early discharge is not appropriate in this case. Patients with PPROM require careful monitoring and management to prevent infections and other complications.
Choice B reason: Discontinuing oxycodone administration may be necessary to prevent potential adverse effects on both the patient and the baby, especially considering the patient's recent delivery and current condition.
Choice C reason: Restricting visitor time can help reduce the risk of infection, especially for a patient with PPROM and a newborn who may have a compromised immune system.
Choice D reason: Providing a breast pump is important to help the mother establish and maintain lactation, especially if the baby is premature and may have difficulty breastfeeding directly.
Correct Answer is A
Explanation
Choice A reason: Encouraging the patient to ambulate intermittently and change positions can help alleviate early decelerations by improving uteroplacental blood flow and promoting fatal oxygenation. Movement and position changes can reduce compression on the umbilical cord and facilitate Labor progression.
Choice B reason: Placing the patient in the left lateral position can improve uteroplacental blood flow, but increasing the oxytocin rate is not indicated based on the current findings. Early decelerations are typically not a sign of Labor dystocia requiring oxytocin augmentation.
Choice C reason: Administering oxygen via a non-rebreather mask is generally reserved for situations where there is significant fatal distress or non-reassuring fatal heart rate patterns. Early decelerations are usually benign and do not necessitate supplemental oxygen.
Choice D reason: Teaching the patient to push when she feels the urge during contractions is appropriate during the second stage of Labor. However, the current findings with early decelerations do not indicate the need for this intervention at this time. The focus should be on monitoring and managing the fatal heart rate.
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