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 ["3"]
Explanation
Step 1: Identify the prescribed dose.
- The prescribed dose is 30 mg.
- Result: 30 mg.
Step 2: Identify the strength of the available tablets.
- The available tablets are 10 mg each.
- Result: 10 mg/tablet.
Step 3: Calculate the number of tablets to administer.
- Number of tablets = (Prescribed dose in mg) ÷ (Strength of available tablets in mg/tablet).
- Number of tablets = 30 mg ÷ 10 mg/tablet.
- Number of tablets = 3 tablets.
- = 3 tablets.
So, the nurse should administer 3 tablets of fluoxetine per dose.
Correct Answer is C
Explanation
Choice A reason: Ulnar Deviation
Ulnar deviation, or the bending of the fingers towards the ulna (the outer bone of the forearm), is more commonly associated with rheumatoid arthritis rather than osteoarthritis. Rheumatoid arthritis typically affects the joints symmetrically and can lead to deformities such as ulnar deviation due to chronic inflammation.
Choice B reason: Symmetric Joints Affected
Symmetric joint involvement is characteristic of rheumatoid arthritis, not osteoarthritis. Osteoarthritis usually affects joints asymmetrically, meaning it can affect one joint more than the other. It commonly affects weight-bearing joints such as the knees, hips, and spine.
Choice C reason: Pain Worsens with Activity
Pain that worsens with activity is a hallmark symptom of osteoarthritis. This condition is caused by the breakdown of cartilage in the joints, leading to pain and stiffness, especially after physical activity. The pain typically improves with rest but can become more persistent as the disease progresses.
Choice D reason: Weight Loss
Weight loss is not a typical manifestation of osteoarthritis. In fact, being overweight or obese is a risk factor for developing osteoarthritis, particularly in weight-bearing joints. Weight management is often recommended to help reduce the stress on affected joints and alleviate symptoms.
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