Safe, Effective Care Environment
39. A nurse receives morning report on today's client assignments. In which order should the nurse assess these children? Place each client in order of priority from first to last.
Safe, Effective Care Environment
39. A nurse receives morning report on today's client assignments. In which order should the nurse assess these children? Place each client in order of priority from first to last.
. A 4-year-old with encopresis and a parent at bedside.
. An 8-year-old in traction for fractured femur, with no parent at bedside.
. A 5-year-old who has just returned from bronchoscopy, with parents at bedside.
. A 12-year-old scheduled today for appendectomy, with no parent at bedside.
Test-Taking Tip
Children with the potential for airway complications (the third client) and hazards of immobility (the second client) should be the nurse's highest priority. Younger children (the third client) and those without a parent (the second client) at the bedside should also be a top priority.
Content Area: Child Health, Hospitalization; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 3. The third client would be seen first because this child has been under recent sedation and has had the airway manipulated. A nurse should assess this child for high risk for respiratory complications. Answer 2. The second client would be seen second because the child should be assessed for potential complications of traction. Additionally, this is a younger school-age child who is in the room alone, needing the nurse's attention to make sure toys, food, etc. are within the child's reach. Answer 4. The fourth client would be seen third because the child has an unstable condition, at risk for rupture of the appendix. The child also needs to be assessed, with documentation done and a presurgical checklist completed, before the child can be transported to surgery as soon as the operating room is ready. This child is usually ambulatory and is old enough to call the nurse for urgent needs; therefore, this child is a lower priority than the child immobilized by traction. Answer 1. The first client would be seen last because the child with encopresis has a condition associated with constipation and fecal retention in which watery colonic contents bypass hard fecal masses and pass through the rectum. This is the lowest priority because this condition does not have the potential for acute complications, and the child's parent is at the bedside.