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 C
Explanation
A. Performing an arterial stick to obtain a PaO2 level is important for diagnostic purposes but does not address the immediate need to improve oxygenation.
B. Obtaining vital signs, including oxygen saturation, is important but should follow the initiation of oxygen therapy to address the immediate threat to the client’s respiratory status.
C. Starting oxygen at 2 liters nasal cannula is the highest priority intervention to immediately improve the client’s oxygenation status and address the acute symptoms of tachypnea and altered mental status.
D. Assessing pain level and last pain medication given is important but secondary to addressing the client's acute respiratory symptoms.
Correct Answer is A
Explanation
A. Increased oxygen saturation indicates that the Venturi face mask is effectively delivering the specified concentration of oxygen. This is the primary goal of using a Venturi mask, which provides precise oxygen delivery to improve oxygen saturation levels.
B. Increased cough productivity is not a direct indicator of the effectiveness of a Venturi face mask. The mask's purpose is to deliver oxygen, not to alter cough patterns.
C. Decreased cough frequency is unrelated to the function of the Venturi face mask. The mask's effectiveness is measured by oxygen delivery rather than changes in cough frequency.
D. Decreased breath sounds are not a direct measure of the effectiveness of a Venturi face mask. Breath sounds could indicate other respiratory issues but do not specifically reflect the effectiveness of oxygen therapy.
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