The nurse receives shift report on four patients. Which patient will the nurse prioritize?

A 5-year-old child admitted with asthma exacerbation who used a rescue inhaler 16 hours ago.

A 3-year-old toddler who swallowed several sunflower seeds and continues to cough with an oxygen saturation of 91%.

A 15-year-old adolescent who had a laparoscopic appendectomy 10 hours ago, rates their pain a 3/10, and is preparing for discharge this morning.

An 18-month-old admitted for dehydration 2 days ago who has had six wet diapers in the last 24 hours and ate 70% of their meals.

Answer and Explanation

The Correct Answer is B

Choice A reason: While a child with asthma exacerbation needs monitoring, they used their rescue inhaler 16 hours ago and are currently stable. This patient is not the highest priority.

Choice B reason: A 3-year-old who continues to cough with an oxygen saturation of 91% is at risk of respiratory distress or obstruction due to the swallowed sunflower seeds. The low oxygen saturation indicates impaired gas exchange and requires immediate attention.

Choice C reason: A 15-year-old recovering from a laparoscopic appendectomy who is stable and preparing for discharge can wait to be seen after more urgent cases.

Choice D reason: An 18-month-old admitted for dehydration who is producing a normal number of wet diapers and eating well indicates improved hydration status and can be seen after addressing the more critical situation.

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Correct Answer is B,A,D,C

Explanation

The correct order is: b, a, d, c

b) Position the patient in a supine position: The first step is to ensure the patient is in a supine position, which is lying on their back. This position provides the best access and visibility for the nurse to assess the fundus effectively. Ensuring the patient is comfortable and relaxed in this position is crucial before beginning the assessment.
a) Place one hand on the lower segment of the uterus: The next step involves placing one hand on the lower segment of the uterus. This helps to stabilize the uterus and provides support while the nurse palpates the fundus. It also prevents any excessive movement that could cause discomfort or complications.
d) Press at the level of the umbilicus to palpate the fundus: The nurse then presses at the level of the umbilicus (belly button) to palpate the fundus. The fundus is the top portion of the uterus, and assessing its position and firmness provides important information about the postpartum recovery process.
c) Gently massage the fundus in a circular motion: Finally, the nurse gently massages the fundus in a circular motion. This action helps to ensure the uterus remains firm and can help in preventing postpartum haemorrhage. If the fundus is not firm, the massage can stimulate uterine contractions to firm it up.

A. Immune globulin given as soon as possible after delivery B. Hepatitis B immune globulin and hepatitis B vaccine given within 12 hours of birth C. Hepatitis B immune globulin given within 20 hours after birth D. Hepatitis B vaccine given 24 hours after birth

Correct Answer is B

Explanation

Choice A reason: Administering immune globulin as soon as possible after delivery is a correct step but does not include the critical combination of both immune globulin and the hepatitis B vaccine, which provides optimal protection for the newborn against hepatitis B.

Choice B reason: The combination of hepatitis B immune globulin and hepatitis B vaccine given within 12 hours of birth is the most effective intervention for preventing hepatitis B transmission from the parent to the infant. This approach ensures immediate passive immunity through the immune globulin and active immunity through the vaccine, significantly reducing the risk of the newborn developing hepatitis B.

Choice C reason: Administering hepatitis B immune globulin within 20 hours after birth delays the initiation of protective measures compared to the 12-hour window. It is essential to provide both immune globulin and the vaccine as early as possible to maximize the protective effect against hepatitis B.

Choice D reason: Administering the hepatitis B vaccine 24 hours after birth is too late for immediate protection against the virus. The combination of immune globulin and vaccine should be provided within the first 12 hours to ensure the highest level of protection for the newborn. Delaying the vaccination could increase the risk of hepatitis B transmission and infection.

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The nurse receives shift report on four patients. Which patient will the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B,A,D,C

Explanation

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Correct Answer is B

Explanation

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