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
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Related Questions
Correct Answer is B
Explanation
A. Protecting the client's left side during transfers is not directly related to addressing neglect syndrome. Clients with right hemisphere strokes may neglect the left side, but the UAP should be guided to approach from the left to help manage the neglect.
B. Demonstrating to the UAP how to approach the client from the left side helps manage the effects of neglect syndrome. Clients with right hemisphere strokes may not be aware of or may ignore the left side, so approaching from this side can improve the client’s awareness and safety.
C. Observing interactions between the client and family members might provide insights into the client’s condition but is not a direct intervention for managing neglect syndrome. The focus should be on practical strategies to help the client with neglect.
D. Asking the UAP to leave the room and assessing the client for bruising does not address the immediate needs of managing neglect syndrome. The priority is to ensure the client is safely engaged and managed, rather than performing a solitary assessment.
Correct Answer is B
Explanation
A. While knowing the number of tablets taken is important for managing chest pain, it is secondary to ensuring that the client can safely administer the medication.
B. Assessing the client's level of orientation and compliance is crucial because the client needs to understand how and when to use the nitroglycerin properly. Misunderstanding or non-compliance could lead to ineffective treatment or potential harm.
C. Checking heart rate and blood pressure is important for assessing the effects of nitroglycerin, but before leaving the medication for self-administration, it is vital to ensure that the client understands how to use the medication.
D. Monitoring hourly urinary output and daily weight is not relevant to the immediate concern of ensuring safe and effective nitroglycerin self-administration.
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