Try Naxlex NCLEX-RN (Free-Trial)

Review H and P and nurse's notes.

What are the first four actions that the nurse should take?

A.

Take the child's pulse

B.

Place a cervical collar on the client

C.

Look for any open wounds

D.

Call child protective services

E.

Determine if the child's airway is clear

F.

Start a peripheral intravenous line

Answer and Explanation

Correct Answer : A,B,C,E

A)    Correct- Assessing the child's pulse helps determine their cardiac status and whether they have a detectable heartbeat. This information is essential for deciding the appropriate interventions.
B)    Correct- Placing a cervical collar is necessary if there is any suspicion of cervical spine injury due to the fall or submersion. This action helps stabilize the neck and prevent further damage to the spine.
C)    Correct- Checking for open wounds is important to assess for potential sources of bleeding or infection that may require immediate attention.
D)    Incorrect- While child safety is important, the immediate priority in this situation is assessing and stabilizing the child's medical condition. Child protective services may be involved later if there are concerns about the circumstances surrounding the incident.
E)    Correct- Assessing the airway is of utmost importance to ensure that the child can breathe. In cases of near-drowning, ensuring a clear airway is crucial for oxygenation.
F)    Incorrect- While establishing intravenous access may be important for certain interventions, it is not one of the immediate priorities in this situation. Ensuring the child's airway, breathing, and circulation take precedence.
 


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

Regular weighing is an essential self-management strategy for clients with heart failure (HF). It helps monitor changes in fluid balance, which is crucial in managing HF symptoms. Sudden weight gain may indicate fluid retention, a worsening of HF, or the need for adjustments in medications or dietary restrictions. Daily weighing provides valuable information for both the client and healthcare provider to assess the effectiveness of the HF management plan.

While performing range of motion exercises and maintaining mobility are important for overall health, they may not be specifically related to the management of heart failure. The focus of discharge teaching for HF is typically on monitoring symptoms, medication management, diet and fluid restrictions, and when to seek medical attention.

Limiting fluid intake to 1,500 mL daily may be a general recommendation for some clients with HF, but it is best to individualize fluid restrictions based on the client's specific needs. The client should follow the fluid restriction prescribed by their healthcare provider, which may vary depending on the severity of HF and other individual factors.

While maintaining a balanced diet, including adequate protein intake, is important for overall health, there may be specific dietary recommendations for clients with HF that go beyond a general instruction to eat a high protein diet. Dietary instructions for HF clients typically include sodium restriction, fluid restriction if necessary, and considerations for comorbidities and medications.

Correct Answer is ["A","C","D","E"]

Explanation

Fever increases fluid loss through perspiration.

Increased respiratory rate can lead to increased fluid loss through evaporation. Increased nasal secretions can result in fluid loss.

High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.

The following findings do not necessarily indicate increased fluid requirements: Blood pressure alone does not indicate increased fluid requirements.

Oxygen saturation within the normal range does not indicate increased fluid requirements.

Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.

Heart rate alone does not indicate increased fluid requirements.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register