A nurse on a pediatric unit is receiving a report from an assistive personnel (AP). Which of the following clients should the nurse plan to visit first?
A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%
A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F)
A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002
A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale
The Correct Answer is C
A. A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%. While status asthmaticus is a serious condition, a pulse oximetry reading of 95% indicates adequate oxygenation, so this child is not in immediate distress.
B. A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F). While the fever requires monitoring and treatment, roseola is typically a self-limiting illness, and this temperature, while high, is not immediately life-threatening.
C. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002. A urine specific gravity of 1.002 indicates very dilute urine, which is concerning for diabetes insipidus and potential dehydration. This condition requires immediate attention to prevent severe dehydration and electrolyte imbalance.
D. A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale. While managing pain in sickle cell anemia is important, the child’s condition is stable, and pain relief can be addressed after assessing the more urgent case of potential dehydration in the child with diabetes insipidus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Restrain the child's arms. Restraining the child's arms is unsafe and can cause injury. It is important to allow the seizure to occur without interference, except to ensure the child’s safety.
B. Insert a padded tongue blade into the child's mouth. This is an outdated and incorrect practice. Inserting anything into a seizing child's mouth can cause injury to the mouth or teeth and poses a choking hazard.
C. Place the child in a side-lying position. This is the correct action as it helps maintain an open airway and allows for drainage of saliva or vomit, reducing the risk of aspiration.
D. Elevate the child's legs on a pillow. This is not an appropriate action during a seizure as it does not address the safety and airway management needs of the child. Keeping the child on their side is more important for airway safety.
Correct Answer is B
Explanation
A. Fruity breath odour: This is a sign of diabetic ketoacidosis (DKA), a condition associated with hyperglycemia, not hypoglycaemia.
B. Diaphoresis: Sweating is a common sign of hypoglycemia due to the body's release of adrenaline in response to low blood sugar levels.
C. Dry mucous membranes: This is typically associated with dehydration and hyperglycemia, not hypoglycaemia.
D. Polyuria: Frequent urination is a symptom of hyperglycemia, as the body tries to excrete excess glucose through the urine.
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