The poison control nurse receives a call from the caregiver of a young school age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

What do you think that the child might have ingested?’

’At what time did the child ingest the substance?'

‘Induce vomiting while you wait for emergency personnel to arrive.'

‘Check breathing and heart rate.’

Answer and Explanation

The Correct Answer is A

In case of suspected ingestion of a poisonous substance, the priority response of the poison control nurse should be to assess the child's vital signs, especially breathing and heart rate, to determine if the child is experiencing any immediate life-threatening symptoms. This information will help the nurse determine the appropriate course of action, such as whether to instruct the caregiver to perform CPR or to immediately call for emergency medical assistance.

Asking about the substance ingested and the time of ingestion are also important pieces of information to gather, but they should not take priority over assessing the child's vital signs. Inducing vomiting is generally not recommended unless instructed to do so by a medical professional, as it can cause further harm if the substance ingested is corrosive or caustic.

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Correct Answer is B

Explanation

: A client with renal disease may have impaired kidney function, which can aﬀect ﬂuid balance in the body. Giving ﬂuids too quickly or increasing the infusion rate too quickly can lead to ﬂuid overload,

which can exacerbate the client's condition. It is important for the nurse to monitor the amount of ﬂuid the client is receiving to ensure that the infusion rate is appropriate for the client's condition and to prevent ﬂuid overload. Checking the intravenous rate every two days is not sufficient; the nurse should monitor the rate regularly and adjust it as necessary based on the client's response.

A. Stop the transfusion. B. Notify the health care provider of the client s response. C. Check the client s vital signs. D. Document the findings.

Correct Answer is A

Explanation

Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.

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The poison control nurse receives a call from the caregiver of a young school age child who may have ingested a poisonous substance. Which is the priority response by the nurse?

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Naxlex Comprehensive Predictor Exams

A client with renal disease requires IV ﬂuids. It is important for the nurse to:

Correct Answer is B

Explanation

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Correct Answer is A

Explanation

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