A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?

A 6-month-old infant who has croup and an O2 saturation of 92% on room air

A 15-year-old adolescent who is 2 hr postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication

A 3-year-old toddler who has gastroenteritis, moderate dehydration, and had two loose bowel movements over the past 24 hr

A 10-year-old child who is awaiting surgery for an appendectomy and experienced sudden relief from pain

None

Answer and Explanation

The Correct Answer is D

The correct answer is D

Choice A Reason: While croup can be serious, an O2 saturation of 92% on room air is generally stable. This child's condition is concerning but not immediately life-threatening.

Choice B Reason: A 15-year-old adolescent who is 2 hours postoperative following an open reduction and internal fixation of the left ankle and is requesting pain medication is in need of comfort measures. Postoperative pain management is important for recovery, but it is not a priority over more critical conditions.

Choice C Reason: A 3-year-old toddler with gastroenteritis, moderate dehydration, and two loose bowel movements over the past 24 hours requires rehydration and monitoring. The normal range for bowel movements varies, but two loose stools in 24 hours for a toddler with gastroenteritis is not unusual. Dehydration can become severe, so this child should be assessed soon, but it is not the most urgent case.

Choice D Reason: This child's sudden relief from pain could be a sign of a perforated appendix, a serious complication that requires immediate medical attention. Therefore, this child's condition is the most urgent and requires immediate assessment.

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Correct Answer is A

Explanation

A. Performing gastrostomy feedings through an established gastrostomy tube is within the scope of practice for an AP, as it is a routine, non-complex task.
B. Evaluating the effectiveness of pain medication requires assessment skills, which fall under the nurse’s scope of practice.
C. Providing client care instructions requires nursing judgment and should be done by the nurse.
D. Teaching a client how to measure their blood pressure involves client education, which is the nurse’s responsibility.

A. A client who has cellulitis and is receiving oral antibiotics every 8 hr B. A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex C. A mother and their newborn 12 hr postdelivery D. A client who has lower extremity weakness and is newly admitted for observation

Correct Answer is A

Explanation

A: A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.

B: A client who is postoperative following an upper endoscopy procedure and is alert but does not have a gag reflex has a high risk of aspiration and airway obstruction due to impaired swallowing function. The client requires close monitoring and intervention until the gag reflex returns, which can take several hours or longer depending on the type and amount of anesthesia used.

C: A mother and their newborn 12 hr postdelivery have not completed the minimum recommended stay of 24 to 48 hours for uncomplicated vaginal deliveries or 72 to 96 hours for cesarean deliveries, according to the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The mother and their newborn require assessment, education, support, and follow-up care to ensure their health and well-being.

D: A client who has lower extremity weakness and is newly admitted for observation has an undiagnosed condition that could indicate a serious neurological or vascular problem, such as stroke, spinal cord injury, or peripheral artery disease. The client requires diagnostic testing, evaluation, treatment, and rehabilitation to prevent further deterioration or complications.

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A nurse on a pediatric unit has received change-of-shift report for four children. Which of the following children should the nurse assess first?

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