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 ["A","B","C","D"]
Explanation
Choice A: Add Cream to Soups
Adding cream to soups is an excellent way to increase both calorie and protein intake. Cream is rich in fat and calories, which can help in weight gain and provide the necessary energy for clients undergoing chemotherapy. Additionally, it enhances the flavor and texture of soups, making them more palatable for clients who may have a reduced appetite due to treatment.
Choice B: Dip Meats in Eggs and Bread Crumbs Before Cooking
Dipping meats in eggs and bread crumbs before cooking adds extra calories and protein. Eggs are a good source of high-quality protein, and bread crumbs add additional calories. This method also helps to create a more appealing texture and flavor, which can be beneficial for clients experiencing taste changes due to chemotherapy.
Choice C: Use Milk Instead of Water in Recipes
Using milk instead of water in recipes is another effective strategy to boost calorie and protein intake. Milk contains essential nutrients, including protein, calcium, and vitamins, which are important for maintaining strength and health during chemotherapy. This substitution can be applied to various recipes, such as oatmeal, mashed potatoes, and smoothies.
Choice D: Top Fruits with Yogurt
Topping fruits with yogurt not only increases calorie and protein intake but also adds beneficial probiotics. Yogurt is a good source of protein and calcium, and when combined with fruits, it provides a nutritious and appealing snack or dessert. This combination can help improve appetite and provide essential nutrients needed during chemotherapy.
Choice E: Increase Fluids During Meals
Increasing fluids during meals is not specifically aimed at increasing calorie and protein intake. While staying hydrated is important, excessive fluid intake during meals can sometimes lead to a feeling of fullness, which may reduce overall food intake. It is better to focus on nutrient-dense foods and beverages that provide both hydration and essential nutrients.
Correct Answer is C
Explanation
Choice A reason: Assist the client to sit upright in a chair for 4 hours at a time:
While it is important to mobilize patients after surgery, sitting upright for 4 hours at a time is excessive and can cause discomfort and strain on the surgical site. Early postoperative care focuses on gradual mobilization and avoiding prolonged positions that could stress the spine.
Choice B reason: Expect clear drainage on the spinal dressing:
Clear drainage on the spinal dressing is not typical and could indicate a cerebrospinal fluid (CSF) leak, which is a serious complication. Any unexpected drainage should be reported to the healthcare provider immediately.
Choice C reason: Log roll the client every 2 hours:
Log rolling is a technique used to turn patients while keeping the spine in alignment. This method is crucial for patients who have undergone spinal surgery to prevent twisting or bending of the spine, which could disrupt the surgical site and impede healing. Regular repositioning also helps prevent pressure ulcers.
Choice D reason: Perform neurological checks every 8 hours:
Neurological checks are essential after spinal surgery to monitor for any changes in sensation, movement, or function. However, these checks are typically performed more frequently than every 8 hours, especially in the immediate postoperative period.
