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 botom.)
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
A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath.
This client has the highest priority, as he or she may be experiencing an acute asthma atack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.
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.
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.
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 B
Explanation
B. Wearing wrist braces or splints at night can help alleviate symptoms of carpal tunnel syndrome by keeping the wrists in a neutral position and reducing pressure on the median nerve. This can help decrease pain and tingling sensations that often worsen at night due to positioning during sleep.
A. While it is important for the client to communicate changes in symptoms to their healthcare provider, worsening pain and tingling at night in bilateral carpal tunnel syndrome is a common symptom and may not require immediate medical intervention.
C. Elevating the hands on two pillows at night may help reduce swelling and alleviate symptoms in some individuals, but it is not specifically indicated for managing carpal tunnel syndrome.
D. Cold compresses may provide temporary relief of symptoms such as pain and inflammation, but they are not typically recommended as a primary treatment for carpal tunnel syndrome, especially before bedtime.
Correct Answer is C
Explanation
C. Risk for aspiration related to vomiting.Nausea and vomiting increase the risk of aspiration because the vomitus can enter the airway if the client is unable to protect their airway effectively. Therefore, it is critical for the nurse to prioritize interventions aimed at reducing the risk of aspiration, such as maintaining the client in a side-lying position and providing suctioning equipment as needed.
A. While renal function impairment is a potential complication of kidney stones, it is not the most immediate concern in this scenario. The client's severe right flank pain, nausea, and vomiting indicate an acute episode of renal colic, where the kidney stone obstructs the urinary tract, causing intense pain and urinary stasis. While impaired renal function is a concern, it is secondary to the immediate risk of aspiration.
B. Acute pain related to the renal calculus is a significant concern for the client and requires prompt intervention to alleviate discomfort. However, in this scenario, the risk of aspiration from vomiting takes precedence over pain management because aspiration poses an immediate threat to the client's respiratory status.
D. While nutritional deficit related to nausea is a valid concern, it is not the highest priority nursing problem in this scenario. The client's nausea and vomiting are acute symptoms requiring immediate attention to prevent complications such as aspiration. Once the risk of aspiration is addressed, nutritional support and interventions to manage nausea can be implemented.
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