A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products.
The child has a chemical smell on their hands, face, and clothes.
After ensuring the airway is patent, which action should the nurse take first?
Obtain equipment for gastric lavage.
Determine the type of chemical exposure.
Assess the child for altered sensorium.
Call the poison control emergency number.
The Correct Answer is B
Choice A rationale
Gastric lavage is a procedure that involves the insertion of a tube into the stomach to remove its contents and is typically used in cases of poisoning or drug overdose. However, it should not be the first action taken. The type of chemical exposure needs to be determined first to guide appropriate treatment.
Choice B rationale
Determining the type of chemical exposure is crucial as it guides the subsequent steps in management. Different chemicals can have different effects on the body and require different treatments.
Choice C rationale
While assessing for altered sensorium is important in a child exposed to chemicals, it is not the first action. The nurse needs to identify the type of chemical the child was exposed to in order to anticipate potential complications and guide treatment.
Choice D rationale
Calling the poison control emergency number is an important step in managing a case of chemical exposure. However, having information about the type of chemical the child was exposed to can make this call more effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.
Choice B rationale
Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.
Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.
Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.
Correct Answer is C
Explanation
Choice A rationale
Ignoring the behavior and proceeding with the IV antibiotic administration is not the best course of action. This would be an invasion of the patient’s privacy and could potentially lead to legal issues. It is important to respect the patient’s privacy and dignity at all times.
Choice B rationale
Instructing the patient to cease the inappropriate behavior is not the best course of action. While the behavior is inappropriate, it is not the nurse’s place to reprimand the patient. This could lead to a breakdown in the nurse-patient relationship and could potentially escalate the situation.
Choice C rationale
Exiting the room and closing the door quietly is the best course of action. This respects the patient’s privacy and allows the patient and visitor to finish their activity. The nurse can then return at a later time to administer the IV antibiotic.
Choice D rationale
Filling out an unusual occurrence report is not necessary in this situation. While the behavior is inappropriate, it is not an unusual occurrence that requires reporting. The nurse should handle the situation professionally and with discretion.
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