Exhibits
Review H and P and nurse's note.
Which are the first four actions that the practical nurse (PN) should do?
Take the child's pulse
Place a cervical collar on the client
Call child protective services
Start a peripheral IV line
Look for any open wounds
Determine if the child's airway is clear
The Correct Answer is A, F, E
A. Take the child's pulse
Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.
F. Determine if the child's airway is clear
Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.
D. Start a peripheral IV line
Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.
E. Look for any open wounds
Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Acceleration refers to a temporary increase in the fetal heart rate of at least 15 beats per minute above the baseline for at least 10 seconds. The observation of the fetal heart rate increasing 15 beats above baseline twice during the test indicates that accelerations are present, which is a reassuring sign of fetal well-being.
B. A nonreactive pattern would indicate that the test did not meet the criteria for accelerations or fetal heart rate reactivity, which is not the case here as the fetal heart rate did exhibit accelerations.
C. Fetal movement could contribute to accelerations but is not the term used to describe the findings of the test itself. The specific observation made was an increase in fetal heart rate, which is classified as an acceleration.
D. A positive tracing indicates that the nonstress test met criteria for fetal well-being, typically with at least two accelerations, but the correct term for the specific observation here is acceleration rather than describing the overall result.
Correct Answer is B
Explanation
A. Breast tenderness is a common side effect of oral contraceptives and is generally not a cause for immediate concern unless accompanied by other symptoms.
B. Left calf pain is a significant finding that could indicate deep vein thrombosis (DVT), a serious condition requiring prompt evaluation and potential treatment to prevent complications such as pulmonary embolism.
C. A change in menstrual flow can occur with oral contraceptives but is usually less critical than other symptoms. It should be monitored but does not indicate an immediate problem.
D. A weight gain of 5 pounds is a relatively minor side effect and not as urgent as symptoms suggestive of a serious condition like DVT.
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