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
A decrease in peripheral edema is an indication that the furosemide medication is effective.
Furosemide is a diuretic that helps to reduce fluid buildup in the body, including peripheral edema, which is a common symptom of heart failure.
Choice B is wrong because furosemide does not directly decrease cardiac output.
Choice C is wrong because furosemide does not increase venous pressure.
Choice D is wrong because furosemide can actually cause a decrease in potassium levels, not an increase.
Correct Answer is D
Explanation
Sudden infant death syndrome (SIDS) death has a devastating effect on parents.
There is no known cause, so parents experience guilt about what they might have done or not done to contribute to the death.
Acknowledging the family members’ feelings of guilt can help provide support to the family.
Choice A is wrong because there are no specific instructions discouraging the parents from allowing siblings to view the body.
Choice B is wrong because avoiding discussing details of the attempt to revive the infant may not necessarily provide support to the family.
Choice C is wrong because while providing a follow-up phone call 1 week following the infant’s death may be helpful, it is not the only action that should be taken by the nurse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today