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
None
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Allow for frequent rest periods throughout the day.
- A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
- B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
- C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain. - D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.
Correct Answer is B
Explanation
- A: Incorrect. Decreased blood pressure is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be monitored and reported.
- B: Correct. Decreased hallucinations are an indication of chlorpromazine effectiveness, as this medication is an antipsychotic that blocks dopamine receptors in the brain and reduces psychotic symptoms such as hallucinations, delusions, and paranoia.
- C: Incorrect. Decreased cholesterol is not an indication of chlorpromazine effectiveness, but rather a potential benefit that may occur due to its effect on lipid metabolism.
- D: Incorrect. Decreased esophageal reflux is not an indication of chlorpromazine effectiveness, but rather a potential adverse effect that should be avoided by taking the medication with food or water and avoiding lying down after administration.
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