A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on the hands, face, and on the front of the child's clothes. After ensuring the airway is patent, which action should the nurse implement first?

Determine type of chemical exposure.

Call poison control emergency number.

Assess child for altered sensorium.

Obtain equipment for gastric lavage.

Answer and Explanation

The Correct Answer is A

A. Determining the type of chemical exposure is critical as it guides subsequent treatment and interventions. Different chemicals require different management strategies, including whether to induce vomiting or administer activated charcoal.

B. Calling poison control is important but should occur after identifying the specific chemical involved, as the poison control guidelines often depend on the substance the child was exposed to.

C. Assessing for altered sensorium is important, but the immediate priority is to identify the type of chemical exposure to implement appropriate interventions.

D. Obtaining equipment for gastric lavage may be necessary in certain cases, but this is based on the type of chemical ingested and the child's condition. Identifying the chemical exposure must occur first to determine if gastric lavage is appropriate.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E","dropdown-group-3":"A"}

Explanation

Dyspnea: Dyspnea, or difficulty breathing, can be a symptom of an adverse reaction such as an allergic reaction, anaphylaxis, or cardiovascular issues. It indicates a severe reaction that affects the respiratory system and requires immediate attention.
Nausea: Nausea is a common symptom of adverse reactions to medications or other substances. It can accompany other symptoms like dizziness or headache and indicates that the client is experiencing an ongoing negative reaction to a treatment or exposure.
Headache: A headache can be a manifestation of various adverse reactions, including those related to medication or changes in blood pressure. It is a significant symptom that may indicate worsening of the client's condition or an ongoing adverse reaction that needs to be addressed.

A. Provide only distilled water. B. Document abdominal girth. C. Offer a high protein diet. D. Use a cushion when sitting.

Correct Answer is B

Explanation

A. Provide only distilled water. Providing only distilled water is not appropriate in this situation.
The client's weight gain and electrolyte imbalance indicate the need for careful monitoring and intervention, but restricting fluid intake to distilled water alone may not address the underlying issues adequately.
B. Document abdominal girth. Documenting abdominal girth is important to assess for signs of ascites, which can occur in hepatic failure. A sudden weight gain and elevated blood pressure may indicate fluid retention, and documenting abdominal girth can provide additional information about fluid accumulation in the abdomen.
C. Offer a high protein diet. While nutritional support is important for clients with hepatic failure, offering a high protein diet may not be appropriate if the client has an electrolyte imbalance. Protein intake should be balanced and monitored carefully to avoid exacerbating the imbalance.
D. Use a cushion when sitting. Using a cushion when sitting may be beneficial for comfort, but it does not directly address the identified issues of electrolyte imbalance, elevated blood pressure, and weight gain. The priority is to assess and address these concerns through appropriate
interventions such as documenting abdominal girth and addressing fluid retention.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E","dropdown-group-3":"A"}

Explanation

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

Correct Answer is B

Explanation

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