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
Explanation
Choice A reason:
Removing all objects that contain latex from the client’s room is important for clients with a latex allergy, not a penicillin allergy. Latex allergies can cause severe reactions, including anaphylaxis, but this action is not relevant to a penicillin allergy.
Choice B reason:
Verifying that the client’s medication prescriptions do not include cephalosporin is crucial because cephalosporins can have cross-reactivity with penicillin. Clients with a penicillin allergy may also react to cephalosporins, so it is essential to avoid prescribing these antibiotics.
Choice C reason:
Notifying dietary services to adjust the client’s diet is not directly related to managing a penicillin allergy. Dietary adjustments are more relevant for clients with food allergies or specific dietary restrictions.
Choice D reason:
Having the client purchase a medication alert bracelet to wear in the hospital is a good practice for general safety, but it is not an immediate action the nurse should take during the admission process. The primary focus should be on ensuring that the client’s medications do not include penicillin or related antibiotics.
Correct Answer is C
Explanation
Choice A: Veracity
Veracity refers to the ethical principle of truthfulness and honesty. In the context of nursing, it involves providing accurate and complete information to patients. While veracity is crucial in maintaining trust between the nurse and the patient, it is not directly related to the decision to discontinue a medication due to adverse effects.
Choice B: Fidelity
Fidelity involves being faithful to commitments and promises made to patients. It includes maintaining confidentiality and being loyal to the patient’s best interests. Although fidelity is important in the nurse-patient relationship, it does not specifically address the ethical considerations involved in discontinuing a harmful medication.
Choice C: Nonmaleficence
Nonmaleficence is the ethical principle of doing no harm. In this scenario, discontinuing the experimental chemotherapy medication due to evidence of rapidly advancing kidney failure aligns with the principle of nonmaleficence. The nurse and healthcare team are acting to prevent further harm to the patient by stopping a treatment that is causing significant adverse effects.
Choice D: Autonomy
Autonomy refers to respecting the patient’s right to make their own decisions about their healthcare. This includes providing the patient with all necessary information to make informed choices. While autonomy is a fundamental ethical principle, the decision to discontinue the medication in this case is primarily based on preventing harm, which aligns more closely with nonmaleficence.