Exam (elaborations) Critical Thinking- Rationale

4. The nurse is caring for clients on the pediatric medical unit. Which client should the nurse assess first? 1. The child diagnosed with type 1 diabetes who has a blood glucose level of 180 mg/dL. 2. The child diagnosed with pneumonia who is coughing and has a temperature of 100°F. 3. The child diagnosed with gastroenteritis who has a potassium (K+) level of 3.9 mEq/L. 4. The child diagnosed with cystic fibrosis who has a pulse oximeter reading of 90%. Rationale Correct - 4. A pulse oximeter reading of less than 93% is significant and indicates hypoxia, which is life threatening; therefore, this child should be assessed first. 5. The nurse has received the a.m. shift report for clients on a pediatric unit. Which medication should the nurse administer first? 1. The third dose of the aminoglycoside antibiotic to the child diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). 2. The IVP steroid methylprednisolone (Solu-Medrol) to the child diagnosed with asthma. 3. The sliding scale insulin to the child diagnosed with type 1 diabetes mellitus. 4. The stimulant methylphenidate (Ritalin) to a child diagnosed with attention deficit-hyperactivity disorder (ADHD).