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.
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Related Questions
Correct Answer is D
Explanation
- A. Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take. However, this should be done after the matter is reported to child protection services.
- B. Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.
- C. Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.
- D.Contacting Child Protective Services is appropriate action for the nurse to take at this point as it is the nurse's legal responsibility to do so.
Correct Answer is A
Explanation
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The correct answer is Choice A.
Choice A rationale: Forming a committee of staff members to investigate current staffing issues is the first step the nurse manager should take. This is because it is important to understand the root cause of the problem before implementing any changes. By forming a committee, the nurse manager can gather different perspectives and insights from the staff members who are directly affected by the staffing issues. This will help in identifying the specific problems and coming up with effective solutions. Furthermore, involving the staff in the decision-making process can increase their acceptance of the changes and reduce resistance.
Choice B rationale: Providing support to staff members who are resistant to staffing changes is an important step, but it should not be the first action. Before providing support, the nurse manager needs to understand the specific issues causing the resistance. This can be achieved by forming a committee of staff members to investigate the staffing issues.
Choice C rationale: Scheduling a staff meeting to present the different options to staff members is a crucial step in the process. However, this should be done after the nurse manager has a clear understanding of the staffing issues and has identified potential solutions. Presenting options without first understanding the problem may lead to ineffective solutions and increased resistance from staff members.
Choice D rationale: Giving the staff members advance written notice of staffing changes is a necessary step to ensure transparency and to give staff members time to adjust. However, this should be done after the nurse manager has identified the staffing issues, explored potential solutions, and decided on the changes to be implemented.
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