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 B
Explanation
Choice A reason:
Health care provider: While health care providers, such as doctors, have extensive knowledge about medications and their uses, they may not always have the most up-to-date information on specific drug compatibilities. Pharmacists specialize in medications and are more likely to have immediate access to detailed compatibility data.
Choice B reason:
Hospital pharmacist: Pharmacists are the primary resource for information on drug compatibility. They have access to comprehensive databases and resources that provide detailed information on drug interactions and compatibility. Consulting the hospital pharmacist ensures that the nurse receives accurate and current information regarding the safe administration of ampicillin and gentamicin sulfate.
Choice C reason:
Nurse manager: Nurse managers oversee nursing staff and ensure that patient care standards are met. While they have a broad knowledge of clinical practices, they may not have the specific expertise or resources to provide detailed information on drug compatibility.
Choice D reason:
Medication sales representative: Medication sales representatives are knowledgeable about the products they promote, but their primary role is to market medications. They may not have the comprehensive and unbiased information needed to determine drug compatibility. It is always best to consult a pharmacist for this type of information.
Correct Answer is B
Explanation
Choice A reason: While some women may start producing milk as early as 24 to 48 hours after delivery, this is not the typical timeframe for most women. The initial milk produced is colostrum, which is different from the mature milk that comes in later.
Choice B reason: For most women, breast milk “comes in” around 3 to 5 days postpartum. This period marks the transition from colostrum to mature milk, which is more abundant and nutritionally rich. During this time, mothers may experience breast engorgement and increased milk production.
Choice C reason:
Breast milk typically does not take about 10 days to come in. By this time, most women will have already transitioned to mature milk. If milk production has not started by this time, it may indicate a problem that requires medical attention.
Choice D reason:
The timeframe of 6 to 8 days is also not typical for the initial onset of mature milk production. Most women will have their milk come in within the first week postpartum.
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