The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?
A 12-year-old reporting neck, arm, and lower back discomfort.
An 8-year-old with a full leg air splint for a possible broken tibia.
A 6-year-old with multiple superficial lacerations of all extremities.
An 11-year-old with a headache, nausea, and projectile vomiting.
The Correct Answer is D
A. A 12-year-old reporting neck, arm, and lower back discomfort:
- This child is reporting discomfort, which is concerning, but it doesn't indicate an immediate life-threatening condition. However, a thorough assessment is needed to rule out any serious injuries, especially to the spine.
B. An 8-year-old with a full leg air splint for a possible broken tibia:
- While a possible broken tibia requires attention, it is not as immediately critical as symptoms such as projectile vomiting. Splinting can help stabilize the limb, but it is not an emergency that requires immediate attention compared to potential neurological issues.
C. A 6-year-old with multiple superficial lacerations of all extremities:
- Superficial lacerations, although they require care, are generally not immediately life-threatening. The child needs appropriate wound care and assessment for any deeper injuries, but this can be addressed in a timely manner without immediate urgency.
D. An 11-year-old with a headache, nausea, and projectile vomiting:
- This is the most concerning presentation among the options. Headache, nausea, and projectile vomiting could be indicative of a severe head injury, and these neurological symptoms require urgent evaluation to assess for conditions such as a concussion, intracranial bleed, or increased intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["400"]
Explanation
To calculate the mL/hr rate for the infusion pump, we can use the following formula: mL/hr = (Total volume to be infused in mL) / (Time in hours)
In this case, the total volume to be infused is 200 mL, and the infusion time is 30 minutes, which is equal to 0.5 hours.
mL/hr = 200 mL / 0.5 hours mL/hr = 400 mL/hr
Therefore, the nurse should program the infusion pump to deliver 400 mL/hr.
Correct Answer is A
Explanation
A low serum creatinine level indicates decreased muscle mass or impaired kidney function. However, it does not necessarily indicate that the 24-hour creatinine clearance test should be withheld or delayed.
Initiating the urine collection as prescribed allows for the accurate assessment of creatinine clearance and provides valuable information about the client's kidney function. The test results can help guide further evaluation and management of the client's condition.
Assessing the client's serum BUN level, notifying the healthcare provider of the results, or assessing for signs of hypokalemia may be relevant in certain situations but are not the immediate priority based on the information provided.
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