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","B","C"]
Explanation
Choice A: Pneumonia
Reason:Postoperative patients, especially those who have undergone abdominal surgery, are at a higher risk of developing pneumonia. This is due to the fact that pain and discomfort can prevent them from taking deep breaths and coughing effectively, which are essential actions to clear the lungs of secretions. The nurse’s notes indicate that the client is refusing to turn and cough due to pain, which further increases the risk of pneumonia. The use of splinting with a pillow when coughing is a technique to help reduce pain and encourage effective coughing, but if the client refuses to comply, the risk remains high.
Choice B: Deep Vein Thrombosis (DVT)
Reason: Deep vein thrombosis is a significant risk for postoperative patients, particularly those who are immobile. The client in this scenario has refused to wear intermittent pneumatic compression devices, which are designed to prevent DVT by promoting blood circulation in the legs. Immobility and the lack of these devices increase the risk of blood clots forming in the deep veins of the legs. If a clot forms and travels to the lungs, it can cause a life-threatening pulmonary embolism. The nurse’s notes emphasize the importance of these devices, but the client’s refusal to use them puts them at a higher risk of developing DVT.
Choice C: Pressure Ulcers
Reason:Pressure ulcers, also known as bedsores, are a common complication for patients who are immobile for extended periods. The client’s refusal to change positions increases the risk of pressure ulcers developing on areas of the body that are in constant contact with the bed. These ulcers can be painful and lead to serious infections if not managed properly. Regular turning and repositioning are crucial in preventing pressure ulcers, and the nurse’s notes highlight the importance of this practice.
Choice D: Urinary Retention
Reason:While urinary retention can be a postoperative complication, it is less likely in this scenario because the client has a Foley catheter in place, which is draining to a bedside bag. The catheter helps to ensure that the bladder is emptied regularly, reducing the risk of urinary retention. Therefore, this is not one of the primary risks for this client based on the provided information.
Choice E: Hemorrhage
Reason:Hemorrhage, or excessive bleeding, is a potential risk after any surgery, including a total abdominal hysterectomy. However, the nurse’s notes indicate that the abdominal dressing is dry and intact, and only scant vaginal bleeding has been observed. This suggests that there is no significant bleeding at this time. While hemorrhage is always a concern, the current observations do not indicate an immediate risk.
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.
