The nurse is assigned to four patients on the pediatric progressive care unit. After receiving shift report, which patient should the nurse see first?
A.
Blood pressure of 88/56 mm Hg in 4-year-old child with heart failure
B.
Child crying inconsolably after his parents went home
C.
Pain 5/10 in a child 2 days after cardiac surgery
D.
Temperature 104.6 °F (40.3 °C) 3 days after dental visit
ANS: D
This child likely has infective endocarditis or bacterial endocarditis. Any high fever after an invasive procedure or dental cleaning needs to be investigated for this possibility. The blood pressure of 88/56 mm Hg is at about the 50% percentile for a 4-year-old and would be considered adequate. Pain is an expected finding after surgery and needs to be treated, but not as the priority. The crying child could be comforted by a nursing assistant, child-life specialist, social worker, or even a volunteer until the nurse can see the child.
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