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: The Health Care Proxy Does Not Go Into Effect Until I Am Incapable of Making Decisions
This statement is correct. A health care proxy, also known as a durable power of attorney for health care, only becomes active when the individual is no longer capable of making their own medical decisions. Until that point, the individual retains full control over their health care choices1.
Choice B: I Have to Choose a Family Member as My Health Proxy
This statement indicates a need for clarification. It is not necessary to choose a family member as a health care proxy. An individual can select any trusted person, whether a family member or a friend, to act as their health care proxy. The most important factor is that the chosen person understands the individual’s wishes and is willing to advocate for them2.
Choice C: I Can Change Who I Designate as My Health Care Proxy at Any Time
This statement is correct. An individual can change their designated health care proxy at any time, as long as they are still capable of making their own decisions. It is important to ensure that any changes are documented properly and that all relevant parties are informed of the change3.
Choice D: If I Become Incapacitated, End-of-Life Choices Will Be Made by My Proxy
This statement is correct. If an individual becomes incapacitated and is unable to make their own medical decisions, the health care proxy will step in to make decisions on their behalf, including end-of-life choices. The proxy should be well-informed about the individual’s preferences and values to make decisions that align with their wishes4.
Correct Answer is A
Explanation
Choice A reason: Check the drainage for glucose:
Clear drainage from the nasal packing after a transsphenoidal hypophysectomy could indicate a cerebrospinal fluid (CSF) leak. CSF leaks are a serious complication that can occur after this type of surgery. Testing the drainage for glucose is a quick and effective way to determine if the fluid is CSF, as CSF contains glucose, whereas normal nasal secretions do not. Identifying a CSF leak promptly is crucial to prevent further complications such as meningitis.
Choice B reason: Notify the client’s provider:
While notifying the provider is important, it should be done after confirming the nature of the drainage. If the drainage is indeed CSF, the provider needs to be informed immediately. However, the initial step should be to check the drainage for glucose to confirm the suspicion.
Choice C reason: Document the amount of drainage:
Documentation is always important in nursing care, but it is not the immediate priority in this situation. The primary concern is to identify the nature of the drainage to address any potential complications promptly.
Choice D reason: Obtain a culture of the drainage:
Obtaining a culture can help identify any infections, but it is not the first step in this scenario. The immediate concern is to determine if the drainage is CSF, which requires checking for glucose.
