# A nurse is caring for patients in a pediatric unit. Which patient should the nurse assess first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=543569  
> language: ko  
> subject: Next Gen NCLEX

## 문제

A nurse is caring for patients in a pediatric unit. Which patient should the nurse assess first?

## 보기

1. A 10-year-old patient with asthma who is scheduled for discharge today and requests assistance with packing.
2. A 12-year-old patient with cystic fibrosis who is receiving oxygen at 2 L/min via nasal cannula and is resting comfortably.
3. A 28-year-old patient who underwent appendectomy 6 hours ago and is now reporting severe abdominal pain (8/10), nausea, and vomiting. **✔ 정답**
4. A 14-year-old patient with migraine who is asking for pain medication for a headache rated 4/10.

**정답: 3**

## 해설

The post-appendectomy patient with severe pain (8/10), nausea, and vomiting requires immediate assessment for potential complications like infection or obstruction. Other patients have non-urgent needs.

## 심화 해설

Clinical Judgment
This question tests Prioritization and Clinical Judgment. The key is to find the "patient who needs to be assessed first." This requires simultaneously considering the ABC (Airway, Breathing, Circulation) principle and potential Risk. The correct answer, patient number 3, complains of severe abdominal pain and nausea/vomiting after surgery, which is a sign of a postoperative complication requiring Notify HCP! immediate reporting to a healthcare provider. Possible causes include ileus, hemorrhage, fistula, peritonitis, etc., which can rapidly worsen and become life-threatening.

Memory Tip
When prioritizing, remember **A**BC and **M**ASLOW's hierarchy of needs. But the most powerful tool is the question, "**What is the most dangerous?**" In this case, the symptoms of patient number 3 carry a much higher **Immediate Risk** than the needs of the other patients.

KR vs US
In Korea, postoperative pain management is more aggressive, and nurses may have relatively more autonomy in administering analgesics. However, in the US NGN/NCLEX, worsening postoperative pain, especially pain accompanied by nausea/vomiting, is emphasized not as a simple failure of pain control, but as a Red Flag for a serious complication that must be assessed and reported. The fact that "the pain has worsened" itself becomes the top priority for assessment.

## 임상 시나리오

Clinical Practice Guide
During early recovery management of a patient after appendectomy, the nurse should monitor for: changes in pain level and characteristics, vomiting or severe nausea, abdominal distension, loss of bowel sounds, fever, and unstable vital signs (especially tachycardia, hypotension). If pain is unrelieved or worsens and is accompanied by nausea/vomiting, report immediately to the physician and request a more detailed evaluation.

Caution
A common pitfall in SATA (Select All That Apply) questions is being led to first identify "the most stable patient" or "the patient who needs education." Always ask first: "Is there an immediate threat to life or function?" Also, the stable condition of a patient with a chronic illness (e.g., COPD, HTN) is a lower priority than the risk of complications after acute surgery.

## 핵심 개념

- **Appendectomy** — Appendectomy. Surgical removal of the appendix at the end of the cecum.
- **Ileus** — Intestinal obstruction. A condition where the bowel's motor function is paralyzed, stopping the movement of contents. Common as a postoperative complication.
- **Peritonitis** — Peritonitis. Inflammation of the peritoneum (the membrane lining the abdominal cavity). It occurs as a complication of conditions such as a ruptured appendix and can be life-threatening.
- **Prioritization** — Priority setting. In the nursing process, ranking the patient's needs or problems according to their urgency and importance.
- **Clinical Judgment** — Clinical judgment. The nurse's ability to collect, interpret, and analyze patient data, draw conclusions, and plan and implement appropriate interventions.

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