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 D
Explanation
Correct Answer is A
Explanation
Choice A rationale:
Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.
Choice B rationale:
Stimulating the client to take deep breaths is not the most immediate action needed in this situation. While deep breathing is important for respiratory function, the client's pain at the groin site requires immediate assessment to rule out complications.
Choice C rationale:
Evaluating the integrity of the IV insertion site is not the primary concern in this case. The client's pain is localized to the groin site, which is where the cardiac catheterization was performed. Checking for hematoma formation at this site takes precedence.
Choice D rationale:
Assessing distal lower extremity capillary refill is important for assessing peripheral perfusion, but it is not the most immediate action needed when a client complains of pain at a specific site, such as the right groin insertion site after a cardiac catheterization. Checking for hematoma and assessing for bleeding should come first.
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