The child is a 2-year-old who fell into a pool. He was retrieved from the pool by a family member but was not breathing. The family member started CPR, and the ambulance brought him to the hospital.
What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion?
Select all that apply.
Temperature of water
The weight of the child
Oxygen concentration of the ambient air
Whether or not anyone witnessed the fall into the pool
The amount of time the child was submerged
Correct Answer : A,E
The level of hypoxemia that the child may have experienced during the submersion depends on several factors, but the most important ones are:
- The **temperature of water**: Cold water can induce a diving reflex, which lowers the heart rate and oxygen consumption, and may protect the brain from hypoxic injury. Cold water can also cause laryngospasm, which prevents water aspiration but also impairs gas exchange.
- The **amount of time the child was submerged**: The longer the submersion, the more severe the hypoxemia and the higher the risk of brain damage and death. The survival rate decreases significantly after 5 minutes of submersion.
The other factors are less relevant or not directly related to the level of hypoxemia:
- The **weight of the child**: This may affect the buoyancy and the ability to float or swim, but not the oxygen consumption or gas exchange during submersion.
- The **oxygen concentration of the ambient air**: This may affect the pre-submersion oxygen saturation, but not the rate of oxygen depletion or gas exchange during submersion.
- The **witnessing of the fall into the pool**: This may affect the time to rescue and resuscitation, but not the level of hypoxemia during submersion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["21"]
Explanation
The correct answer is 21 gtt/min,
To calculate the flow rate (in gtt/min), you can use the following formula: Flow rate (gtt/min) = (Volume to be infused in mL ÷ Time in minutes) × Drop factor (gtt/mL) In this case, the volume to be infused is 1 liter, which is equivalent to 1000 mL. The time for infusion is 12 hours, which is equivalent to 720 minutes. The drop factor is given as 15 gtt/mL. Flow rate (gtt/min) = (1000 mL ÷ 720 min) × 15 gtt/mL = (1.39 gtt/min) × 15 gtt/mL ≈ 20.83 gtt/min Rounded to the nearest whole number, the nurse should regulate the infusion at 21 gtt/min.
Correct Answer is B
Explanation
Choice A rationale:
Leaving the client alone to give them space is not an appropriate intervention for a client with depression and a history of suicide attempts. Isolation can increase feelings of hopelessness and despair, potentially leading to self-harm or suicidal thoughts.
Choice B rationale:
Removing any potential means of self-harm from the client's environment is the most essential intervention in this scenario. It is crucial to ensure the client's safety by eliminating access to items or substances that could be used for self-harm, such as medications, sharp objects, or other dangerous items. This intervention helps reduce the immediate risk of harm.
Choice C rationale:
Encouraging the client to confront their feelings of hopelessness is important in the long term, as it can be part of therapeutic interventions. However, it should not be the immediate priority when the client is at risk of self-harm. Ensuring their safety is paramount.
Choice D rationale:
Telling the client that they should be grateful for what they have is not an appropriate intervention. It can be perceived as dismissive of their feelings and may worsen their sense of hopelessness and isolation.
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