Review H and P and nurse's notes.

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

Take the child's pulse

Place a cervical collar on the client

Look for any open wounds

Call child protective services

Determine if the child's airway is clear

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.

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

Explanation

A) Correct- The duration of submersion is a critical factor in determining the potential level of hypoxemia. Prolonged submersion leads to a higher risk of severe hypoxia and its associated complications.
B) Incorrect- While water temperature can affect the body's response to submersion, it is not directly related to the level of hypoxemia. Hypoxemia primarily results from the lack of oxygen intake during submersion.
C) Correct- Witnessing the fall into the pool is important because immediate initiation of cardiopulmonary resuscitation (CPR) can improve the chances of a positive outcome. Bystander CPR can help maintain oxygenation and circulation until professional help arrives.
D) Correct- The oxygen concentration in the surrounding air is crucial for oxygen delivery to the body's tissues. In cases of submersion, the availability of oxygen in the air the child is breathing plays a role in determining the level of hypoxemia.
E) Incorrect- The weight of the child is not a significant factor in determining the level of hypoxemia during submersion. The primary determinants are factors like submersion duration, availability of oxygen, and prompt initiation of CPR.

A. Wear protective goggles while performing the procedure. B. Apply a water soluble lubricant to the catheter. C. Instill 3 mL of normal saline before suctioning. D. Instruct the client to cough as the suction tip is removed.

Correct Answer is A

Explanation

Wearing protective goggles is important during suctioning to protect the nurse's eyes from potential splashes or aerosolized secretions. Suctioning can generate forceful coughing, gagging, or sneezing in the client, which may cause secretions or mucus to be expelled forcefully and potentially come into contact with the nurse's eyes. Wearing goggles helps prevent eye exposure and reduces the risk of infection transmission.

Applying a water-soluble lubricant to the catheter may be necessary to facilitate the insertion of the suction catheter into the tracheostomy tube, but it is not the most crucial action to include when performing suctioning.

Instilling normal saline before suctioning is not recommended as it can cause potential harm to the client's airway. Instilling saline can lead to bronchospasm, mucosal damage, and other complications. Suctioning should only be performed when necessary to remove secretions and maintain a patent airway.

Instructing the client to cough as the suction tip is removed is not necessary or recommended. Coughing during the suctioning process can be uncontrolled and may increase the risk of trauma to the airway. The nurse should instead provide supportive care and reassurance to the client throughout the procedure.

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Review H and P and nurse's notes. What are the first four actions that the nurse should take?

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Naxlex Comprehensive Predictor Exams

Exhibits here Review H and P. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

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

Explanation

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is A

Explanation

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