A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?
Remove clothing.
Administer pain medication.
Assess respiratory status.
Insert a Foley catheter.
The Correct Answer is C
A. Remove clothing. Removing clothing is important to prevent further injury from retained heat or chemicals, but it is not the first priority compared to ensuring a patent airway and adequate breathing.
B. Administer pain medication. Pain management is important but comes after ensuring the child's airway and respiratory status are stable.
C. Assess respiratory status. Burns on the face and chest can compromise the airway and breathing. Assessing respiratory status is the first priority to ensure the child’s airway is not obstructed and that they are receiving adequate oxygen.
D. Insert a Foley catheter. Inserting a Foley catheter may be necessary to monitor urine output and assess kidney function in severe burns, but it is not the first priority compared to assessing respiratory status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Evaluate the child's self-esteem. Self-esteem evaluation is important in general nursing care but is not a specific intervention for managing urinary tract infections.
B. Encourage frequent voiding. Frequent voiding helps to flush out bacteria from the urinary tract and prevents stasis, which can reduce the risk of urinary tract infections.
C. Administer an antidiuretic. Antidiuretics reduce urine output and are not typically used in the treatment of urinary tract infections, which require adequate urine flow to flush out bacteria.
D. Restrict fluids. Adequate hydration is important in managing urinary tract infections to promote urine flow and help flush out bacteria. Fluid restriction is not appropriate unless otherwise indicated.
Correct Answer is D
Explanation
A. Insulin is absorbed most rapidly when injected in the thigh. Insulin is actually absorbed most rapidly in the abdomen, not the thigh.
B. Use cold insulin for injection to minimize site pain. Insulin should be at room temperature for injection to reduce discomfort and avoid altered absorption rates. Cold insulin can increase injection pain.
C. Massage the site after injection to promote absorption. Massaging the injection site can cause unpredictable insulin absorption and is not recommended.
D. Rotate the injection site to keep insulin levels consistent. Rotating the injection sites helps prevent lipodystrophy and ensures consistent insulin absorption. It helps maintain stable blood glucose levels.
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