A nurse in an emergency department is caring for a child who experienced a submersion injury.
Which of the following is the priority action for the nurse to take?
Assist with intubation
Obtain an ABG sample
Administer an IV bolus
Apply warming blankets
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: Assisting with intubation is the priority action. A submersion injury can cause respiratory distress or failure, and ensuring a clear airway is critical. Intubation is often necessary to maintain oxygenation and prevent complications like hypoxia or aspiration.
Choice B rationale: Obtaining an ABG sample is important to assess the child’s oxygenation and acid-base balance, but it is not the priority action. Ensuring the airway is clear and secured takes precedence over diagnostic tests.
Choice C rationale: Administering an IV bolus might be necessary for fluid resuscitation if the child is experiencing shock, but establishing and maintaining the airway is the first critical step in managing submersion injuries.
Choice D rationale: Applying warming blankets can be important to prevent hypothermia, especially if the child has been in cold water. However, addressing airway and breathing issues is the top priority before initiating warming measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
A toddler repeatedly refusing to let a nurse auscultate his lungs is not necessarily an indicator of child abuse. It could be due to fear, discomfort, or lack of understanding about the procedure.
Choice B rationale
An 8-month-old infant crying when his parents leave the room is a normal developmental behavior known as separation anxiety, and it is not an indicator of child abuse.
Choice C rationale
A mother hesitating to comfort her 6-month-old infant could be due to various reasons, including stress, depression, or lack of knowledge about infant care. While it could potentially be a sign of neglect, it is not a definitive indicator of child abuse.
Choice D rationale
A toddler having bruises on his knees is a common occurrence due to their active nature and frequent falls. However, if the bruises are frequent, unexplained, or have distinct patterns, they could be potential indicators of child abuse.
Correct Answer is A
Explanation
Choice A rationale
Using clean technique to change the tracheostomy tube is an appropriate action for a nurse to take when performing tracheostomy care for a toddler. This helps prevent infection and keeps the tracheostomy tube functioning properly.
Choice B rationale
Cleaning around the stoma with full-strength hydrogen peroxide is not typically recommended. Hydrogen peroxide can be too harsh for the sensitive skin around the stoma.
Choice C rationale
Placing the child in the Trendelenburg position (head lower than the feet) when performing care is not typically recommended. This position could increase the risk of aspiration.
Choice D rationale
Having the child flex his head when securing the ties is not typically recommended. This could cause discomfort or put pressure on the tracheostomy tube.
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