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 C

Explanation

- A. Incorrect. Evaluating dietary intake requires nursing judgment and knowledge of nutrition and eating disorders. This task should not be delegated to an AP.

- B. Incorrect. Measuring vital signs of a postoperative client requires nursing assessment and monitoring for complications. This task should not be delegated to an AP.

- C. Correct. Arranging the lunch tray for a client who has a hip fracture is a routine task that does not require nursing skills or judgment. This task can be delegated to an AP.

- D. Incorrect. Assessing I&O for a client who is receiving dialysis requires nursing knowledge of fluid and electrolyte balance and renal function. This task should not be delegated to an AP.

A. The LPN and AP lower the side rails before lifting the client up in bed. B. Prior to lifting the client, the LPN and AP raise the bed to waist level. C. The LPN and the AP grasp the client under his arms to lift him up in bed. D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.

Correct Answer is C

Explanation

- A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.

- B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.

- C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.

- D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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