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 B
Explanation
A relaxed facial expression can indicate that the medication is having a therapeutic effect and that the infant is experiencing pain relief.
Choice A is wrong because bradycardia is not an indication that the medication is having a therapeutic effect.
Choice C is wrong because increased blood pressure is not an indication that the medication is having a therapeutic effect.
Choice D is wrong because limb withdrawal is not an indication that the medication is having a therapeutic effect.
Correct Answer is A
Explanation
Choice A: Gentamicin is an aminoglycoside antibiotic that can cause nephrotoxicity. Nephrotoxicity refers to kidney damage and can be demonstrated by rising serum creatinine levels. A creatinine level of 1.4 mg/dL is higher than the normal range and may indicate impaired kidney function 2.
Choice B is wrong because Creatinine 0.3 mg/dL is not an answer because it falls within the normal range for creatinine levels.
Choice C is wrong because BUN 12 mg/dL is not an answer because it falls within the normal range for BUN levels.
Choice D is wrong because BUN 6 mg/dL is not an answer because it falls within the normal range for BUN levels.
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