The practical nurse (PN) is assisting in a community center clinic when four clients simultaneously arrive seeking help. In which order should the PN prioritize care to be provided based on the client needs? (Arrange the client with the highest priority first, on top, and lowest priority last, on bottom.)
A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.
A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.
A 10-year-old child with bleeding lacerations on both knees after falling on the playground.
A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
The Correct Answer is A,B,C,D
This client has the highest priority, as he or she may be experiencing an acute asthma attack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.
B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.
This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.
C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground.
This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inflammation.
D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.
This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
When a primigravida client confides in the practical nurse (PN) about being in an abusive relationship, the primary concern is the safety and well-being of the client and her unborn child. Providing contact information for a women's shelter is the most appropriate response in this situation. Women's shelters provide a safe haven for individuals experiencing domestic violence and can offer immediate assistance, including shelter, counseling, legal support, and other resources.
Let's evaluate why the other options are incorrect:
B. Safety plan to keep in a purse at all times:
While a safety plan is essential for individuals experiencing domestic violence, providing a safety plan alone may not address the immediate danger the client is facing. It is crucial to prioritize the client's safety by connecting her with a women's shelter where she can receive comprehensive support.
C. Visit summary documenting the report of abuse:
While it is important to document any reports of abuse, providing a visit summary alone does not address the urgent need for the client's safety. Documentation can be helpful for future reference, but immediate action should be taken to ensure the client's well-being.
D. Paperwork needed to file a restraining order:
Filing a restraining order is a legal step that may be necessary in cases of domestic violence, but it should be pursued after ensuring the client's immediate safety. Providing paperwork alone does not address the client's immediate need for a safe environment. Connecting the client with a women's shelter is a more appropriate course of action to ensure her safety and well-being.
Correct Answer is B
Explanation
A. Enrolling the UAP in a hospital education class on conducting safe client care is unnecessary at this moment. The immediate concern is ensuring the client's safety during the procedure.
B. Stopping the procedure and instructing the UAP to place the client in Fowler's position (or at least semi-Fowler's) is the correct action. This position helps prevent aspiration during oral hygiene for an unconscious client.
C. Praising the UAP for performing oral hygiene does not address the safety risk present in this situation. While family participation is encouraged, it should not be the focus here.
D. Telling the UAP to continue because the unconscious client is positioned safely is incorrect, as the flat side-lying position increases the risk of aspiration. Ensuring the client is positioned properly is essential for their safety.
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