A nurse on a pediatric unit is reviewing her client assignment following the shift report. Which of the following clients should the nurse plan to assess first?
An infant who has pertussis and is receiving oxygen via nasal cannula.
A school-age child who has diabetes mellitus and requires blood glucose monitoring.
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.
A toddler who has both arms in casts and needs to be fed his breakfast.
The Correct Answer is A
Choice A reason:
An infant who has pertussis and is receiving oxygen via nasal cannula: Pertussis, also known as whooping cough, is a highly contagious respiratory disease that can be particularly severe in infants. The fact that the infant is receiving oxygen indicates respiratory distress, which is a critical condition requiring immediate attention. Infants with pertussis are at high risk for complications such as pneumonia, apnea, and respiratory failure. Therefore, this patient should be assessed first to ensure their airway and breathing are adequately supported.
Choice B reason:
A school-age child who has diabetes mellitus and requires blood glucose monitoring: While it is important to monitor blood glucose levels in children with diabetes mellitus to prevent hypo- or hyperglycemia, this condition is generally more stable and manageable compared to the acute respiratory distress seen in the infant with pertussis. Blood glucose monitoring can be scheduled and managed, making it a lower priority in this context.
Choice C reason:
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions: Sickle cell crisis can be extremely painful and requires careful management. However, if the adolescent is ready for discharge, it indicates that their condition has stabilized. Providing discharge instructions is important but can be deferred until more critical patients are assessed.
Choice D reason:
A toddler who has both arms in casts and needs to be fed his breakfast: While this toddler requires assistance with feeding due to their casts, this situation does not pose an immediate threat to their health. Feeding can be managed after ensuring that more critical patients, such as the infant with pertussis, are stable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Promoting oral hygiene is important for preventing infection and maintaining overall health, especially after surgery involving the mouth. However, it is not the immediate priority in the postoperative period.
Choice B reason:
Ensuring adequate nutrition is crucial for healing and recovery, but it is not the most urgent concern immediately after surgery. Nutritional needs can be addressed once the client is stable and the risk of complications has been minimized.
Choice C reason:
Preventing aspiration is the priority action. After surgery for a fractured mandible with intermaxillary fixation, the client is at high risk for aspiration due to the inability to open the mouth and clear secretions effectively. Aspiration can lead to serious complications such as pneumonia, making it the most critical concern.
Choice D reason:
Relieving the client’s pain is important for comfort and recovery, but it is not the highest priority immediately after surgery. Pain management should be addressed once the client’s airway and breathing are secure.
Correct Answer is B
Explanation
Choice A reason: Tamoxifen
Tamoxifen is a medication primarily used to treat breast cancer. It works as a selective estrogen receptor modulator (SERM), which means it blocks estrogen receptors in breast tissue. Estrogen can promote the growth of breast cancer cells, so blocking its effects can help to slow or stop the growth of these cells. However, tamoxifen is not typically used for prostate cancer because prostate cancer is driven by androgens (male hormones) rather than estrogens.
Choice B reason: Leuprolide
Leuprolide is a medication commonly used in the treatment of prostate cancer. It is a type of hormone therapy known as a luteinizing hormone-releasing hormone (LHRH) agonist. Leuprolide works by reducing the production of testosterone, a hormone that can stimulate the growth of prostate cancer cells. By lowering testosterone levels, leuprolide helps to slow the progression of prostate cancer and can be used in various stages of the disease.
Choice C reason: Finasteride
Finasteride is a medication used to treat benign prostatic hyperplasia (BPH) and male pattern baldness. It works by inhibiting the enzyme 5-alpha-reductase, which converts testosterone to dihydrotestosterone (DHT). While finasteride can reduce the size of the prostate and improve urinary symptoms in BPH, it is not typically used as a primary treatment for prostate cancer. Its role in prostate cancer is more preventive, as it can lower the risk of developing the disease.
Choice D reason: Cyclophosphamide
Cyclophosphamide is a chemotherapy drug used to treat various types of cancer, including lymphomas, leukemias, and some solid tumors. It works by interfering with the DNA of cancer cells, preventing them from dividing and growing. While cyclophosphamide can be used in certain cancer treatments, it is not a standard treatment for prostate cancer. Prostate cancer is more commonly treated with hormone therapy, targeted therapy, or other specific chemotherapy agents.
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