A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury.
Which of the following actions should the nurse take first?
Assess respiratory status.
Inspect for fluid leaking from the ears.
Examine the scalp for lacerations.
Check pupil reactions.
The Correct Answer is A
The first action the nurse should take is to assess the respiratory status of the infant.
After a head injury, it is important to ensure that the child’s airway is clear and that they are breathing adequately.
This is a crucial step in providing care for a patient with a head injury.
Choice B is wrong because inspecting for fluid leaking from the ears is not the first priority.
Choice C is wrong because examining the scalp for lacerations is not the first priority.
Choice D is wrong because checking pupil reactions is not the first priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Ataxia is a neurological sign that refers to a lack of muscle coordination and can cause staggering. Inhalation of gasoline vapors can cause symptoms such as dizziness or lightheadedness, headache, facial flushing, coughing or wheezing, staggering, slurred speech, blurry vision and weakness.
Choice B is wrong because Hypothermia is not an answer because hypothermia refers to a dangerously low body temperature and is not a symptom of gasoline inhalation.
Choice C is wrong because Hyperactive reflexes are not an answer because hyperactive reflexes refer to overactive or overresponsive reflexes and are not a symptom of gasoline inhalation.
Choice D is wrong because Pinpoint pupils are not an answer because pinpoint pupils refer to abnormally small pupils and are not a symptom of gasoline inhalation.
Correct Answer is B
Explanation
Maintaining a patent intravenous catheter is important for administering antibiotics and other medications to treat osteomyelitis.
Choice A is wrong because contact precautions are not necessary for a child with osteomyelitis.
Choice C is wrong because a high-calorie, low-protein diet is not indicated for a child with osteomyelitis.
Choice D is wrong because frequent physical activity may not be appropriate for a child with osteomyelitis due to pain and inflammation 1.
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