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 B
Explanation
Choice A Reason:
Vesicles on the skin are more commonly associated with cutaneous anthrax, not inhalation anthrax. Cutaneous anthrax typically presents with a raised, itchy bump that develops into a painless sore with a black center.
Choice B Reason:
Respiratory failure is a severe and common symptom of inhalation anthrax. Inhalation anthrax begins with flu-like symptoms but can rapidly progress to severe respiratory distress, shock, and often death if not treated promptly.
Choice C Reason:
Flu-like symptoms are indeed an early sign of inhalation anthrax, but they are not specific enough to indicate exposure definitively. These symptoms include sore throat, mild fever, fatigue, and muscle aches.
Choice D Reason:
Coughing of blood can occur in the later stages of inhalation anthrax as the disease progresses and the respiratory system becomes severely compromised.
Correct Answer is B
Explanation
Choice A reason:
Clean clothing is important for comfort and hygiene during a disaster, but it is not typically considered an essential item for a basic disaster preparedness kit. Essential items focus on survival needs such as food, water, and medical supplies.
Choice B reason:
Personal identification is crucial in a disaster situation. It helps in verifying identity, accessing services, and reuniting with family members. Important documents such as identification cards, insurance policies, and bank records should be included in a waterproof container.
Choice C reason:
The recommendation is to have one gallon of water per person per day for at least three days, which totals three gallons, not quarts. Water is essential for drinking and sanitation.
Choice D reason:
Matches can be useful for starting fires for warmth or cooking, but they are not considered a primary necessity in a basic disaster preparedness kit. More critical items include food, water, and medical supplies.
Choice E reason:
Prescription medications are essential for individuals who rely on them for chronic conditions. Having an adequate supply of necessary medications can be life-saving during a disaster when access to pharmacies may be limited.