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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
Correct Answer is B
Explanation
A. An upper respiratory infection 2 days ago is not a contraindication for the MMR vaccine. The vaccine can be administered once the child has recovered from the acute illness.
B. Correct. An allergy to neomycin, which is an antibiotic, is a contraindication for
receiving the MMR vaccine. Neomycin is present in trace amounts in the MMR vaccine, and individuals with a severe allergy to this antibiotic should not receive the vaccine.
C. A temperature of 37.2° C (99° F) is a low-grade fever and is not a contraindication for the MMR vaccine. Mild illness without fever is not a contraindication.
D. A family history of seizures is not a contraindication for the MMR vaccine. The vaccine can be safely administered to children with a family history of seizures.
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