An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?

Left 5th intercostal space midclavicular line

Right carotid area

Over the brachial artery

Over the sternum

Answer and Explanation

The Correct Answer is C

A. Left 5th intercostal space midclavicular line: Palpating the left 5th intercostal space midclavicular line is not appropriate for assessing pulse in an unresponsive infant. This location is typically used for cardiac auscultation and not for pulse assessment.
B. Right carotid area: Palpating the carotid artery is not recommended in infants due to the risk of causing injury to the delicate structures of the neck, including the
airway and blood vessels.

C. Over the brachial artery: The brachial artery is the preferred site for assessing pulse in infants. It is located in the inner aspect of the upper arm and can be easily palpated. In an unresponsive infant, the brachial pulse should be assessed before
initiating CPR.

D. Over the sternum: Palpating over the sternum is not an appropriate site for pulse assessment in infants. The sternum is a bone and does not contain any major arteries suitable for pulse palpation.

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Correct Answer is C

Explanation

A. Maintaining nasal packing may be important post-hypophysectomy to prevent bleeding or cerebrospinal fluid leaks. However, in the context of Cushing's disease, ensuring oral hygiene is
paramount due to increased risk of infection, especially if the patient is on corticosteroid therapy, which suppresses the immune system.

B. Keeping the head of the bed at 30° helps prevent complications such as cerebral edema and increased intracranial pressure. While this is important post-hypophysectomy, it's not specific to Cushing's disease or a priority over oral care.

C. Providing frequent mouth care is crucial in Cushing's disease due to increased cortisol levels leading to immunosuppression and susceptibility to infections. Additionally, glucocorticoid therapy can cause mucosal dryness and ulceration, necessitating meticulous oral hygiene.

D. Monitoring intake and output is essential postoperatively to assess fluid balance and renal function. While important, it's not the priority in this context compared to oral care, especially considering the risk of dehydration due to increased cortisol levels in Cushing's disease.

A. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. B. Remind the UAP to apply a fitted respirator mask before entering the client's room. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Assign the UAP to provide care for another client and assume full care of the client.

Correct Answer is C

Explanation

A. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. While important, this does not address the immediate issue of appropriate personal protective equipment (PPE).

B. Remind the UAP to apply a fitted respirator mask before entering the client's room. A fitted respirator mask is not necessary for influenza, which typically requires droplet precautions, not airborne precautions.
C. Review the need for the UAP to wear a face mask while in close contact with the client.

Influenza is spread through respiratory droplets, so a face mask is necessary for close contact to prevent transmission.
D. Assign the UAP to provide care for another client and assume full care of the client. This is not necessary if the UAP is appropriately trained and reminded to use the correct PPE.

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An infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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