A nurse is caring for a child who is brought to the urgent care clinic following exposure to poison ivy 1 hr ago. Which of the following actions should the nurse take first?
Administer an oral corticosteroid.
Apply calamine lotion to the affected area.
Instruct the parent to give the child an oatmeal bath twice daily.
Flush the area with cold, running water.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale: Administering an oral corticosteroid is not the first action the nurse should take. Corticosteroids are used to reduce inflammation and itching caused by poison ivy. However, they are usually prescribed if the symptoms are severe or if the rash covers a large area of the body. It’s important to note that corticosteroids can have side effects, especially when used for a long time, so they should be used under the supervision of a healthcare provider.
Choice B rationale: Applying calamine lotion to the affected area can help soothe the skin and relieve itching caused by poison ivy. However, this is not the first action the nurse should take. The first step is to remove the oil from the skin that causes the allergic reaction. Calamine lotion can be applied after the area has been thoroughly washed.
Choice C rationale: Instructing the parent to give the child an oatmeal bath twice daily can help soothe the skin and relieve itching. However, this is not the first action the nurse should take. Similar to calamine lotion, an oatmeal bath can be beneficial after the area has been thoroughly washed to remove the oil from the skin.
Choice D rationale: The first action the nurse should take when caring for a child exposed to poison ivy is to flush the area with cold, running water. This helps to remove the oil (urushiol) from the skin that causes the allergic reaction. It’s important to do this as soon as possible after exposure to help prevent the spread of the oil to other areas of the body or to other people. After flushing the area, the nurse can then apply calamine lotion or recommend an oatmeal bath to help soothe the skin and relieve itching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Obtain the specimen by swabbing the infant's rectum using a sterile culture swab. This is the correct choice. When collecting a stool specimen from an infant, the rectal swab method is commonly used. A sterile culture swab helps prevent contamination and ensures accurate results for detecting the presence of ova and parasites in the stool.
Choice B rationale:
Place a urine collection device on the infant until the specimen is obtained. This choice is not appropriate for collecting a stool specimen. A urine collection device is used for collecting urine, not stool. The specimen for ova and parasites needs to be taken directly from the rectum or diaper to accurately identify any infestations.
Choice C rationale:
Transfer the specimen to the collection container using povidone-iodine-soaked gauze. While povidone-iodine is an antiseptic, it is not typically used to transfer stool specimens. Using a sterile swab or a clean, dry container is more suitable for collecting and transporting stool samples to the lab.
Choice D rationale:
Maintain the specimen at room temperature after collection until it is transferred to the lab. Stool specimens for ova and parasites usually require refrigeration to prevent the degradation and growth of potential pathogens. Room temperature might lead to the overgrowth of bacteria and parasites, affecting the accuracy of test results.
Correct Answer is C
Explanation
The correct answer is choice C. 6.8 to 7.7 kg (15 to 17 lb).
Choice A rationale:
This weight range is above the average for a 6-month-old infant. According to growth charts, the 50th percentile weight for a 6-month-old male is approximately 7.9 kg (17 lb 8 oz), and for a female, it’s about 7.3 kg (16 lb 1 oz). Therefore, 8.6 to 9.5 kg would be considered above average and not the anticipated weight for most infants.
Choice B rationale:
This weight range is below the average for a 6-month-old infant. The average weight at 6 months is significantly higher than 4.1 to 5 kg, as infants are expected to double their birth weight by 5 months of age. Therefore, an infant weighing between 9 to 11 lb at 6 months would be considered underweight.
Choice C rationale:
This weight range is within the average for a 6-month-old infant. As mentioned, the 50th percentile weights for 6-month-old infants are approximately 7.9 kg for males and 7.3 kg for females. This choice falls within the expected weight gain trajectory where an infant is anticipated to double their birth weight by 5 months and then gain an additional pound or so by 6 months.
Choice D rationale:
This weight range is significantly above the average for a 6-month-old infant. It is well above the 95th percentile for this age group and would be considered unusual without underlying health conditions that could contribute to such a weight at this age. An infant weighing between 23 to 25 lb at 6 months would be exceptionally rare and likely indicative of an abnormal growth pattern.
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