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 D
Explanation
Choice A: Plan of care changes for the upcoming shift
Plan of care changes for the upcoming shift are typically included in the “Recommendation” segment of SBAR. This section focuses on what actions need to be taken next, including any changes in the care plan that the oncoming nurse should be aware of. It ensures that the incoming nurse knows what to expect and what specific tasks or interventions are required during their shift.
Choice B: Intracranial pressure readings
Intracranial pressure (ICP) readings are crucial for monitoring a client with a traumatic brain injury. However, these readings are more appropriately included in the “Assessment” segment of SBAR. The assessment section provides an analysis of the client’s current condition, including vital signs, lab results, and other critical data. This information helps the oncoming nurse understand the client’s current status and any immediate concerns.
Choice C: Glasgow results
The Glasgow Coma Scale (GCS) results are used to assess the level of consciousness in clients with brain injuries. These results should also be included in the “Assessment” segment of SBAR. The GCS score provides valuable information about the client’s neurological status and helps guide clinical decisions. Including this information in the assessment ensures that the oncoming nurse has a clear understanding of the client’s current condition.
Choice D: Code status
Code status is a critical piece of information that should be included in the “Background” segment of SBAR. The background section provides relevant clinical history and context for the current situation. Knowing the client’s code status (e.g., full code, do not resuscitate) is essential for making informed decisions about their care, especially in emergency situations. Including this information in the background ensures that the oncoming nurse is aware of the client’s preferences and legal directives.
Correct Answer is A
Explanation
Choice A: Wrap the stump with an elastic bandage in a figure-eight configuration
Wrapping the stump with an elastic bandage in a figure-eight configuration is a standard practice in postoperative care for below-the-knee amputations. This method helps to shape and shrink the residual limb, preparing it for a prosthesis fitting. The figure-eight wrap provides even compression, which helps to reduce swelling and promote proper healing. It also helps to prevent the formation of edema and ensures that the residual limb maintains a conical shape, which is ideal for fitting a prosthetic socket.
Choice B: Remove the elastic bandage and re-wrap the stump once per day
While it is important to regularly check and adjust the bandage, removing and re-wrapping the stump only once per day may not be sufficient. The bandage should be checked more frequently to ensure it remains properly positioned and provides consistent compression. In some cases, it may need to be adjusted multiple times a day to maintain the desired level of compression and to prevent any issues such as slippage or uneven pressure.
Choice C: Perform passive range of motion exercises once daily
Performing passive range of motion exercises is beneficial for maintaining joint flexibility and preventing contractures. However, these exercises should be performed more frequently than once daily, especially in the early postoperative period. Regular exercises help to maintain muscle strength, improve circulation, and promote overall mobility. The frequency and type of exercises should be tailored to the individual needs of the client and guided by a physical therapist.
Choice D: Secure the elastic bandage to the lowest joint
Securing the elastic bandage to the lowest joint is not recommended. The bandage should be wrapped in a way that provides even compression without restricting movement or circulation. The figure-eight configuration is preferred because it allows for better control of the compression and helps to shape the residual limb effectively. Securing the bandage to a joint can lead to discomfort and may impede proper blood flow.