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?

Apply warming blankets.

Administer an IV bolus.

Assist with intubation.

Obtain an ABG sample.

Answer and Explanation

The Correct Answer is C

A. Applying warming blankets is important for maintaining the child's body temperature, but it is not the top priority in this situation.

B. Administering an IV bolus may be necessary, but it is not the priority action. The child's airway and breathing take precedence.

C. This is the correct action. In cases of submersion injury, there is a risk of respiratory distress or failure due to aspiration of water. Assisting with intubation helps ensure a patent airway and adequate oxygenation.

D. Obtaining an arterial blood gas (ABG) sample is an important assessment, but it is not the top priority. Ensuring a patent airway and providing adequate oxygenation come first.

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Correct Answer is B

Explanation

A. Starting the IV in the infant's foot is not the preferred site for a 12-month-old who is ambulatory or beginning to walk, as it can interfere with mobility. The hand, forearm, or scalp (if necessary) are preferred sites.
B. Using a 24-gauge catheter is the correct choice, as smaller-gauge catheters (24- to 26-gauge) are appropriate for infants to minimize trauma and facilitate proper IV access.
C. Changing the IV site every 3 days is a general guideline for adults, but in infants, the site should be assessed frequently and changed as needed based on signs of infiltration or complications.
D. Covering the insertion site with an opaque dressing is incorrect because a transparent dressing is preferred to allow for continuous assessment of the site for complications such as infiltration or phlebitis.

A. "I will ensure that my child is tested for tuberculosis every year." B. "My child will need to double his medications for the next 6 months." C. "The risk of transmission decreases once my child is on zidovudine for 2 weeks." D. "My child will need to repeat his childhood immunizations once he is in remission."

Correct Answer is A

Explanation

A. This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.

B. Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.

C. While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of
treatment. It takes longer for the viral load to decrease significantly.

D. Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may be
individualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.

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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?

Nursing Test Bank

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