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: Leave the pad in place for at least 40 minutes
Leaving the aquathermia pad in place for at least 40 minutes is not recommended. The typical duration for applying an aquathermia pad is 20 to 40 minutes1. Prolonged exposure beyond this time can lead to complications such as burns or vasoconstriction, where blood vessels constrict instead of dilate, potentially increasing blood pressure and causing discomfort.
Choice B: Set the pad’s temperature to 42.2°C (108°F)
Setting the pad’s temperature to 42.2°C (108°F) is too high. The recommended temperature range for an aquathermia pad is generally between 40.5°C to 43°C (105°F to 109.4°F)3. Temperatures above this range can increase the risk of burns and skin damage. It is crucial to follow the manufacturer’s guidelines and institutional protocols to ensure safe and effective use of the pad.
Choice C: Use safety pins to keep the pad in place
Using safety pins to keep the pad in place is not safe. Safety pins can puncture the pad, causing leaks and potentially leading to electrical hazards. Instead, the pad should be secured with tape or a cloth cover to ensure it stays in place without causing damage.
Choice D: Stop the treatment if the client’s skin becomes red
Stopping the treatment if the client’s skin becomes red is the correct action. Redness of the skin can indicate the beginning of a burn or other skin damage. It is essential to monitor the client’s skin condition frequently during the application of heat therapy and to discontinue the treatment immediately if any signs of adverse reactions, such as redness or discomfort, are observed.
Correct Answer is C
Explanation
Choice A reason: Pruritus:
Pruritus, or itching, can be uncomfortable and may indicate underlying conditions such as dry skin, allergies, or liver disease. However, it is not typically an immediate threat to health and can often be managed with topical treatments or antihistamines.
Choice B reason: Swollen gums:
Swollen gums can be a sign of gingivitis or other dental issues. While important to address, it is not usually an urgent condition unless it is causing severe pain or infection. Dental problems can lead to complications if untreated, but they are generally not life-threatening.
Choice C reason: Dysphagia:
Dysphagia, or difficulty swallowing, is a serious condition that can lead to aspiration, malnutrition, and dehydration. It can be caused by neurological disorders, structural abnormalities, or other medical conditions. Because it can directly impact the client’s ability to eat and drink safely, it is a priority for immediate assessment and intervention.
Choice D reason: Urinary hesitancy:
Urinary hesitancy, or difficulty starting urination, can be a symptom of benign prostatic hyperplasia (BPH) or other urinary tract issues. While it can cause discomfort and lead to urinary retention, it is generally not as immediately life-threatening as dysphagia.