Difficulty: Medium
Average Score: 79%
Simulated
A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?
Correct answer
A
Rationale
The correct answer is A: A 12-year-old child who has cystic fibrosis and reports difficulty clearing secretions. This child should be assessed first because difficulty clearing secretions can lead to respiratory distress and potential airway obstruction, which are life-threatening in children with cystic fibrosis. Assessing and addressing this issue promptly is crucial to prevent respiratory compromise.
Choice B: The 3-year-old child with an atrial septal defect and a heart rate of 120/min is stable and does not require immediate assessment unless there are signs of distress.
Choice C: The 5-year-old child with type 1 diabetes mellitus and a blood sugar of 150 mg/dL is within the target range and does not require immediate assessment.
Choice D: The 2-year-old child with diarrhea and abdominal pain is a lower priority compared to the child with cystic fibrosis experiencing difficulty clearing secretions.
Choice B: The 3-year-old child with an atrial septal defect and a heart rate of 120/min is stable and does not require immediate assessment unless there are signs of distress.
Choice C: The 5-year-old child with type 1 diabetes mellitus and a blood sugar of 150 mg/dL is within the target range and does not require immediate assessment.
Choice D: The 2-year-old child with diarrhea and abdominal pain is a lower priority compared to the child with cystic fibrosis experiencing difficulty clearing secretions.