Try our free nursing testbanks today. click here to join
Teas 7 test, Hesi A2 and Nursing prep
Nursingprepexams LEARN. PREPARE. EXCEL!
  • Home
  • Nursing
  • TEAS
  • HESI
  • Blog
Start Studying Now

Take full exam for free

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?

A.

An infant who has pertussis and is receiving oxygen via nasal cannula.

B.

A school-age child who has diabetes mellitus and requires blood glucose monitoring.

C.

An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions.

D.

A toddler who has both arms in casts and needs to be fed his breakfast.

Answer and Explanation

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.


Free Nursing Test Bank

  1. Free Pharmacology Quiz 1
  2. Free Medical-Surgical Quiz 2
  3. Free Fundamentals Quiz 3
  4. Free Maternal-Newborn Quiz 4
  5. Free Anatomy and Physiology Quiz 5
  6. Free Obstetrics and Pediatrics Quiz 6
  7. Free Fluid and Electrolytes Quiz 7
  8. Free Community Health Quiz 8
  9. Free Promoting Health across the Lifespan Quiz 9
  10. Free Multidimensional Care Quiz 10
Take full exam free

View Related questions

Correct Answer is B

Explanation

Choice A reason: Draw sheet:

A draw sheet can be used to assist in repositioning a patient, but it is not the most effective method for turning a client who has undergone spinal fusion. The primary concern is to maintain spinal alignment, which is best achieved through the log roll technique.

Choice B reason: Log roll:

The log roll technique is the preferred method for turning patients who have had spinal surgery. This technique involves moving the patient as a single unit, keeping the spine in alignment to prevent any twisting or bending that could disrupt the surgical site. It is especially important for obese patients to ensure that the spine remains stable during movement.

Choice C reason: Sliding board:

A sliding board is typically used to assist with transfers from one surface to another, such as from a bed to a wheelchair. It is not suitable for turning a patient in bed, particularly one who has had spinal surgery.

Choice D reason: Hoyer lift:

A Hoyer lift is a mechanical device used to lift and transfer patients who are unable to move themselves. While it can be useful for transferring patients, it is not designed for turning patients in bed and does not provide the necessary support to maintain spinal alignment during a turn.

Correct Answer is B

Explanation

Choice A: Hypophosphatemia

Hypophosphatemia, or low phosphate levels, is not typically associated with prerenal acute kidney injury (AKI). Prerenal AKI is primarily related to decreased blood flow to the kidneys, which does not directly affect phosphate levels. Hypophosphatemia is more commonly seen in conditions such as refeeding syndrome, chronic alcoholism, and certain endocrine disorders.

Choice B: Hyperkalemia

Hyperkalemia, or elevated potassium levels, is a common electrolyte imbalance in prerenal acute kidney injury (AKI). When kidney function is impaired, the kidneys are less able to excrete potassium, leading to its accumulation in the blood. This can result in dangerous cardiac arrhythmias and requires prompt management. Hyperkalemia is often seen in various types of AKI, including prerenal, intrinsic, and postrenal causes.

Choice C: Hypercalcemia

Hypercalcemia, or high calcium levels, is not typically associated with prerenal AKI. In fact, AKI can sometimes lead to hypocalcemia (low calcium levels) due to impaired kidney function affecting calcium and phosphate metabolism. Hypercalcemia is more commonly associated with conditions such as hyperparathyroidism, malignancies, and certain medications.

Choice D: Hypernatremia

Hypernatremia, or high sodium levels, is also not a typical finding in prerenal AKI. Prerenal AKI is usually characterized by volume depletion, which can lead to hyponatremia (low sodium levels) due to the body’s attempt to retain water and maintain blood pressure. Hypernatremia is more commonly seen in conditions involving excessive water loss or inadequate water intake.

Quick Links

Nursing Teas Hesi Blog

Resources

Nursing Test banks Teas Prep Hesi Prep Nursingprepexams Blogs
© Nursingprepexams.com @ 2019 -2025, All Right Reserved.