Nokea
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?
- A. An infant who has pertussis and is receiving oxygen via nasal cannula
- B. An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions
- C. A school-age child who has diabetes mellitus and requires blood glucose monitoring
- D. A toddler who has both arms in casts and needs to be fed his breakfast
Correct Answer: A
Rationale: The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause severe respiratory distress. Assessing the infant's respiratory status is crucial as pertussis can lead to respiratory failure. Oxygen therapy is essential for maintaining adequate oxygenation levels. The nurse must monitor the infant's respiratory rate, effort, and oxygen saturation levels to ensure proper oxygenation. This assessment takes priority over the other clients' needs.
Choice B is incorrect because although the adolescent has sickle cell crisis, they are stable and ready for discharge instructions, which can be addressed after the critical assessment of the infant is completed.
Choice C is incorrect as monitoring blood glucose levels in a child with diabetes is important but does not take precedence over assessing a critically ill infant with pertussis.
Choice D is incorrect as feeding a toddler with both arms in casts can be challenging but does not pose an immediate threat to their health compared to the infant with pertussis requiring oxygen.
In
You may also like to solve these questions
A charge nurse is reviewing documentation in the medical record from a newly licensed nurse. Click to highlight the findings that indicate this nurse requires additional education.
- A. The client is inappropriate and is a huge fall risk
- B. The provider has denied this RN's requests for physical or chemical restraints
- C. They appear 'medically stable
- D. the partner is at bedside and said that their spouse is always complaining or arguing
- E. Morphine 10mg IV given orally
- F. The client has a history of major depressive disorder and alcohol use disorder
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. A indicates the nurse's lack of understanding of patient safety by not recognizing the fall risk. B suggests a lack of knowledge on restraint alternatives. C shows an inadequate assessment of the patient's overall condition. D reflects poor communication skills and lack of understanding of family dynamics. Choices E and F are not necessarily indicative of a need for additional education based on the information provided.
A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?
- A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output
- B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL
- C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache
- D. A client who was administered acyclovir for cellulitis reports pain in the affected leg
Correct Answer: B
Rationale: The nurse should assess the client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL first. Hypoglycemia (low blood sugar) can lead to serious complications, including confusion, seizures, and loss of consciousness. Immediate intervention is necessary to prevent further deterioration. Choice A could indicate hematuria, which also requires attention but is not immediately life-threatening. Choices C and D do not present immediate life-threatening situations.
A nurse is teaching a class on torts. The nurse should include which of the following situations as an example of negligence?
- A. A client who is alert and oriented makes an informed decision to leave the hospital against medical advice. The nurse applies restraints to the client to prevent him from leaving.
- B. A nurse identifies the absence of peripheral pulsation in a casted extremity in the early morning and reports it to the provider in the early afternoon.
- C. A client who is competent refuses an antidepressant medication. The nurse dissolves the medication in food and administers it to her without her knowledge.
- D. A nurse finds a client who is on a low-sodium diet eating salted potato chips. The nurse tells the client that she will apply wrist restraints if he does not stop eating the potato chips.
Correct Answer: C
Rationale: The correct answer is C because administering medication without the client's knowledge and against their refusal constitutes a breach of the duty of care and violates the client's autonomy and right to make decisions about their own treatment. This is an example of negligence as it goes against the ethical principle of informed consent. Choices A, B, and D do not meet the criteria for negligence as they involve actions taken in the best interest of the client, such as preventing harm or reporting concerning findings to the provider. In choice A, the nurse is trying to prevent harm by applying restraints to a client who is making a potentially harmful decision. In choice B, the nurse is identifying and reporting a concerning clinical finding promptly. In choice D, the nurse is attempting to educate the client and prevent harm related to dietary restrictions.
A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?
- A. A client requesting a referral for home health services
- B. A client asking about his PCA pump that contains morphine
- C. A client who needs assistance with a bath
- D. A client who has questions about his new prescription
Correct Answer: B
Rationale: The correct answer is B. The nurse should plan to care for the client asking about his PCA pump with morphine first. This is because the client's inquiry relates to pain management, which is a priority in nursing care. Pain management directly impacts the client's comfort and well-being. Addressing the client's concerns about the PCA pump promptly ensures proper pain relief and prevents potential complications. Clients requesting referrals, assistance with baths, or questions about prescriptions can be attended to after the client with immediate pain management needs is addressed.
A nurse is supervising a licensed practical nurse (PN) who is providing care to a client who is postoperative. Which of the following statements by the client requires the nurse to follow up with the PN?
- A. Do you know when I will be going home?
- B. My dressing was changed earlier this morning.
- C. I have not received any of my medications today.
- D. I do not know how to make the remote control work.
Correct Answer: C
Rationale: Correct Answer: C. "I have not received any of my medications today."
Rationale: This statement is concerning as it indicates a potential oversight in medication administration, which is crucial for postoperative clients. The nurse should follow up with the PN to ensure that the client receives the necessary medications promptly.
Summary of Other Choices:
A: Asking about discharge is appropriate and does not require immediate follow-up.
B: Reporting that the dressing was changed is a positive sign of wound care management.
D: Not knowing how to use the remote control is not a priority in postoperative care.
Overall, choice C stands out as it directly relates to the client's well-being and should be addressed promptly.