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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View Related questions
Correct Answer is A
Explanation
Choice A reason: Place a pillow under the client’s head:
During a tonic-clonic seizure, it is crucial to protect the client’s head from injury. Placing a pillow or any soft object under the head can help prevent head trauma caused by the convulsions. Ensuring the client’s safety by protecting their head is a primary concern during a seizure.
Choice B reason: Insert a padded tongue blade into the client’s mouth:
This action is incorrect and potentially dangerous. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or jaw. It can also obstruct the airway. The myth that a person can swallow their tongue during a seizure is false, and no object should be placed in the mouth.
Choice C reason: Apply a face mask for oxygen administration:
While providing oxygen can be beneficial after the seizure has ended, during the seizure, the priority is to ensure the client’s safety and prevent injury. Applying a face mask during the active phase of a seizure is not practical and can interfere with managing the seizure safely.
Choice D reason: Gently restrain the client’s extremities:
Restraining the client’s extremities during a seizure is not recommended. Attempting to restrain the movements can cause injury to both the client and the nurse. The focus should be on protecting the client from harm without restricting their movements.
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.