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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:

Limiting each of the client's visitors to 2 hours per day is not a necessary precaution for a client undergoing brachytherapy with a low-dose radiation implant. The duration of visitor stays does not directly impact the effectiveness of the treatment or the safety of the client.

Choice B rationale:

Instructing visitors to stay 1 m (3.3 feet) away from the client is not a standard practice for patients undergoing brachytherapy. Radiation safety protocols are in place to protect both the patient and visitors. However, the exact distance may vary based on the specific treatment and facility guidelines.

Choice C rationale:

Attaching a dosimeter to the client's gown is the correct action. A dosimeter measures the amount of radiation exposure received by the client. This information is crucial for healthcare providers to monitor the client's radiation dose, ensuring it stays within safe limits and effectively targets the cancer cells.

Choice D rationale:

Straining the client's urine is not directly related to brachytherapy with a low-dose radiation implant. This intervention is more relevant in situations where kidney stones or other urinary obstructions are suspected. It is not a standard practice for patients undergoing brachytherapy.

A. Delegate non-nursing tasks to ancillary staff. B. Stock client rooms with extra supplies. C. Assign dedicated equipment to each client's room. D. Change continuous IV infusion tubing every 24 hr.

Correct Answer is A

Explanation

- A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.

- B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.

- C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.

- D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer.Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

A nurse manager is preparing an educational session for nursing staff about how to provide cost-effective care. Which of the following methods should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving enteral feedings via an NG tube.The client has developed hyperosmolar dehydration.Which of the following actions should the nurse take when administering the client's feedings?

A nurse is teaching a class about using niacin to reduce LDL cholesterol.The nurse should include in the teaching that which of the following conditions is a contraindication for receiving this medication?

A nurse is caring for a female client who requires bed rest and reports difficulty urinating into a bedpan.Which of the following actions should the nurse take?

A nurse is planning postoperative care for a client who is scheduled for a thoracotomy with chest tube placement. Which of the following pieces of equipment should the nurse plan to have at the client's bedside?

A nurse manager is preparing to teach a group of newly licensed nurses about effective time management. Which of the following steps of the time management process should the nurse manager include as the priority?

A nurse is assessing a newborn's heart rate. Which of the following actions should the nurse take?

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?

A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?