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 C
Explanation
A sausage-shaped abdominal mass is a symptom of intussusception in infants.
Intussusception is a serious condition where part of the intestine slides into an adjacent part of the intestine, often blocking food or fluid from passing through and cutting off the blood supply to the affected part of the intestine.
Choice A is wrong because a board-like abdomen is not a symptom of intussusception.
Choice B is wrong because increased urinary output is not a symptom of intussusception.
Choice D is wrong because constipation is not a symptom of intussusception.
Correct Answer is A
Explanation
A 24-gauge catheter is the smallest-gauge catheter and is appropriate for administering IV fluids and medications to an infant.
Choice B is wrong because an opaque dressing would prevent the nurse from visualizing the insertion site.
Choice C is wrong because starting an IV in an infant’s foot can be painful and difficult to secure.
Choice D is wrong because IV sites should be changed every 72-96 hours or according to facility policy.
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