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 D
Explanation
A. The cream should be removed after it has been on the skin for the recommended amount of time. It is typically wiped off before the procedure.
B. The medication should applied repeatedly to provide analgesia
C. Washing the site with alcohol before applying the cream is not necessary and may cause unnecessary skin irritation.
D. Lidocaine and prilocaine cream typically require about 60 minutes to take effect.
Correct Answer is C
Explanation
A. Hypertension is not a typical finding in severe dehydration. In fact, dehydration often leads to decreased blood pressure.
B. Increased urine output is not a typical finding in severe dehydration. Dehydration leads to decreased urine output as the body tries to conserve fluids.
C. This is the correct answer. In severe dehydration, the body compensates by increasing the respiratory rate to try to maintain oxygen levels and remove excess carbon dioxide. This is a compensatory mechanism in response to metabolic acidosis, which can occur with dehydration.
D. A capillary refill of 2 seconds indicates normal perfusion. In severe dehydration, capillary refill may be prolonged, indicating poor perfusion.
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