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.
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Correct Answer is ["B","C","D","E"]
Explanation
Choice A: WBC Count
Reason:The white blood cell (WBC) count is not directly related to fall risk. WBC count is an indicator of the immune system’s response to infection or inflammation. In this case, the patient’s WBC count is within the normal range (5,000 to 10,000/mm³) on both days. Therefore, it does not contribute to an increased risk of falls.
Choice B: Parkinson’s disease
Reason:Parkinson’s disease significantly increases the risk of falls due to several factors. Patients with Parkinson’s often experience postural instability, which is the inability to maintain balance when standing or walking. This condition is a cardinal feature of Parkinson’s disease and can lead to frequent falls. Additionally, Parkinson’s patients may experience freezing of gait, where they suddenly cannot move their feet forward despite the intention to walk. This can cause them to fall. Other gait abnormalities, such as festinating gait (short, rapid steps) and dyskinesias (involuntary movements), also contribute to the increased fall risk.
Choice C: Potassium level on day 2
Reason:The patient’s potassium level on day 2 is 3.0 mEq/L, which is below the normal range of 3.5 to 5 mEq/L. Low potassium levels (hypokalemia) can lead to muscle weakness, cramps, and fatigue. These symptoms can impair the patient’s ability to maintain balance and increase the risk of falls. Hypokalemia can also cause abnormal heart rhythms, which can further contribute to the risk of falls.
Choice D: Furosemide
Reason:Furosemide is a diuretic medication used to treat conditions such as heart failure by reducing fluid buildup in the body. However, it can also cause orthostatic hypotension, a condition where blood pressure drops significantly when standing up. This can lead to dizziness, lightheadedness, and an increased risk of falls. Additionally, furosemide can cause electrolyte imbalances, such as low potassium levels, which can further contribute to fall risk.
Choice E: Low blood pressure
Reason: The patient’s blood pressure readings indicate orthostatic hypotension, with a significant drop from 128/56 mm Hg while sitting to 92/40 mm Hg while standing. Orthostatic hypotension is a common condition in patients with Parkinson’s disease and heart failure. It can cause dizziness, lightheadedness, and fainting when changing positions, increasing the risk of falls. The patient’s low blood pressure when standing is a clear indicator of increased fall risk.
Correct Answer is D
Explanation
Choice A reason:
Albuterol is primarily a bronchodilator and does not significantly reduce inflammation. Anti-inflammatory medications, such as corticosteroids, are typically used to address inflammation in the airways.
Choice B reason:
While albuterol can help reduce coughing episodes by opening the airways and making breathing easier, it is not its primary function. Coughing can be a symptom of bronchospasm, which albuterol helps to relieve.
Choice C reason:
Albuterol is effective in preventing wheezing by relaxing the muscles around the airways, which helps to open them up and allow more air to flow through. This action helps to alleviate wheezing, a common symptom of asthma and other respiratory conditions.
Choice D reason:
The primary function of albuterol is to open the airways. It is a bronchodilator that works by relaxing the smooth muscles around the airways, allowing them to widen and making it easier to breathe.
Choice E reason:
Albuterol does not stimulate the flow of mucus. Its main action is to relax the airway muscles and improve airflow. Mucus production is typically managed by other medications or treatments.