Difficulty: Medium
Average Score: 90%
Simulated
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?
Correct answer
A
Rationale
The correct answer is A. The nurse should assess the infant with pertussis receiving oxygen first because pertussis can cause respiratory distress. Assessing the oxygenation status is a priority to ensure the infant is receiving adequate oxygenation. This can prevent potential complications such as respiratory failure. The other clients have important needs but do not have immediate life-threatening conditions requiring urgent assessment. The school-age child with diabetes requires monitoring but can wait a little longer. The adolescent in sickle cell crisis ready for discharge instructions can be assessed after ensuring the infant's immediate needs are addressed. The toddler with both arms in casts needing feeding can also wait since feeding can be done after the infant's urgent assessment.