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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is []

Explanation

Actions to Take:

A. Educate on disease process and management: Rheumatoid arthritis (RA) is a chronic

autoimmune disorder characterized by inflammation of the synovial membrane, leading to joint pain, swelling, and stiffness. Educating the client about RA helps them understand the disease, its

progression, treatment options, and the importance of adherence to prescribed medications and lifestyle modifications. This empowers the client to actively participate in managing their condition and improve outcomes.

B. Turn every two hours to offload bony prominences to prevent pressure injuries: Rheumatoid arthritis predisposes individuals to joint deformities and immobility due to joint inflammation and pain. Immobility increases the risk of pressure injuries, especially over bony prominences. Turning the client every two hours helps redistribute pressure, reduces the risk of pressure ulcers, and maintains skin integrity.

Potential Condition:

D. Rheumatoid arthritis: The client's clinical presentation, including bilateral joint pain and stiffness, positive rheumatoid factor, positive antinuclear antibody test, elevated erythrocyte sedimentation rate (ESR), and soft tissue swelling with marginal erosions on hand X-rays, is consistent with rheumatoid arthritis (RA). RA is a chronic autoimmune disease characterized by inflammation of the synovial joints, leading to joint damage, pain, and functional impairment.

Parameters to Monitor:

C. Pain: Monitoring pain is essential in rheumatoid arthritis management to assess the effectiveness of pain management interventions and adjust treatment accordingly. Pain assessment tools, such as numerical rating scales or visual analog scales, help quantify pain intensity and guide pain management strategies.

D. Skin breakdown: Rheumatoid arthritis can limit mobility and predispose individuals to prolonged immobility, increasing the risk of pressure injuries. Monitoring for signs of skin breakdown, such as erythema, blanchable or non-blanchable skin changes, and skin integrity over bony prominences, helps prevent pressure ulcers and facilitates early intervention if skin breakdown occurs. Regularly turning the client, maintaining proper positioning, and providing adequate support surfaces are essential to prevent pressure injuries.

A. Administer oxygen via face mask. B. Apply an Internal fetal heart monitor. C. Notify the healthcare provider. D. Use a vibroacoustic stimulator.

Correct Answer is A

Explanation

A. Administer oxygen via face mask. The decrease in fetal heart rate after contractions indicates possible fetal distress. Administering oxygen to the mother can increase oxygen delivery to the fetus, potentially improving fetal oxygenation and alleviating distress.
B. Apply an Internal fetal heart monitor. While continuous monitoring is important, the first priority is to address the immediate fetal distress. Monitoring alone will not address the issue.
C. Notify the healthcare provider. Notifying the provider is important, but addressing the immediate fetal distress takes priority.
D. Use a vibroacoustic stimulator. Vibroacoustic stimulation can be used to assess fetal well- being, but it does not address the underlying fetal distress, which is the priority.

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Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Correct Answer is A

Explanation

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4 mL". How many ml. should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

A nurse is caring for a toddler who has respiratory syncytial virus. Which of the following actions should the nurse plan to take?

Exhibits Following the fluid bolus, the client is more awake and able to answer questions. What questions are appropriate for the secondary survey? Select all that apply.

Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

Exhibits here The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart. For each body system, click to specify the assessment findings that indicates hypoxia.