A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
Collect a stool sample for ova and parasites from a school-age child
Engage a toddler in play.
The Correct Answer is A
Rationale:
A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.
B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.
C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.
D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Fill the bath basin with tap water that is 39° C (102.2° F) is too warm for bathing; the recommended water temperature is typically around 37°C (98.6°F) to prevent burns or discomfort.
B. Pull the curtain around the client's bed ensures privacy for the client during the bath, which is important for maintaining dignity and confidentiality.
C. Wash the client's arms and hands first is not necessarily the first step; typically, washing the face and then moving to the rest of the body is preferred.
D. Use a washcloth to wipe the client's eyes from the outer canthus to the inner canthus is incorrect as it should be done from the inner canthus to the outer canthus to avoid spreading any discharge across the eye.
Correct Answer is B
Explanation
Rationale:
A. “There are no provider's prescriptions available.” This reflects the Situation (current problem), not background.
B. The B (Background) step of SBAR includes relevant clinical history and context that led to the current situation. Explaining how the client was found provides important background information that helps the provider understand the circumstances surrounding the client’s condition.
C. “The client should be seen by a neurologist.” This is part of the Recommendation step, where the nurse suggests actions or next steps.
D. “The client is disoriented. Pupils are slow to respond to light.” This belongs in the Assessment step, as it describes the nurse’s clinical findings.
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