A 3-year-old child presents in the pediatric emergency room and is very lethargic. The mother found her in the medication cabinet at home but is unsure what she ingested. What is the nurse’s first priority?

Obtain a better history to determine what the child ingested

Obtain vital signs and assess for perfusion

Assess the child’s airway and breathing

Administer activated charcoal via nasogastric tube

Answer and Explanation

The Correct Answer is C

Choice A reason: Obtaining a detailed history is important to identify the ingested substance, but it is not the first priority in a lethargic child. Lethargy may indicate compromised airway, breathing, or circulation, which are life-threatening. Addressing immediate physiological stability takes precedence over history collection in an emergency setting.

Choice B reason: Obtaining vital signs and assessing perfusion is critical in evaluating a child with potential poisoning, but it is secondary to ensuring airway and breathing stability. Lethargy may signal respiratory depression or hypoxia, which require immediate assessment to prevent further deterioration before vital signs are fully evaluated.

Choice C reason: Assessing the child’s airway and breathing is the first priority in a lethargic child with suspected ingestion. Lethargy may indicate central nervous system depression or hypoxia, which can compromise airway patency and respiratory function. Immediate assessment ensures life-threatening conditions are addressed first, following the ABCs (airway, breathing, circulation) of emergency care.

Choice D reason: Administering activated charcoal may be appropriate to prevent absorption of certain toxins, but it is not the first priority. Without ensuring airway and breathing stability, charcoal administration could be unsafe, especially if the child is lethargic and at risk for aspiration, making this a secondary intervention.

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Correct Answer is ["83"]

Explanation

Step 1: Convert the child’s weight from pounds to kilograms. 96.8 lbs ÷ 2.2 = 44 kg Result at step 1 = 44 kg

Step 2: Apply the Holliday-Segar formula.

For the first 10 kg: 100 mL/kg × 10 kg = 1000 mL

For the next 10 kg: 50 mL/kg × 10 kg = 500 mL

For the remaining weight (44 kg - 20 kg = 24 kg): 20 mL/kg × 24 kg = 480 mL Result at step 2 = 1000 mL + 500 mL + 480 mL = 1980 mL

Step 3: Adjust for vomiting. Since the child has been vomiting, maintenance fluids are typically not increased unless specified (e.g., for dehydration). The question asks for maintenance fluids, so we use the standard calculation from Step 2. Result at step 3 = 1980 mL for 24 hours

Step 4: Calculate the hourly rate. 1980 mL ÷ 24 hours = 82.5 mL/hour Result at step 4 = 82.5 mL/hour

Step 5: Round to the nearest whole number. 82.5 rounded to the nearest whole number = 83 mL/hour

Final answer 83 mL/hour

A. Your child will need immediate hospitalization for chelation therapy B. We will monitor the lead levels and provide nutritional counseling C. No treatment is needed since the child is asymptomatic D. Environmental changes are sufficient to manage this level

Correct Answer is A

Explanation

Choice A reason: A blood lead level of 48 µg/dL in a 24-month-old is significantly elevated, requiring immediate chelation therapy to remove lead from the body. Even asymptomatic children are at risk for neurological damage, developmental delays, and organ toxicity, necessitating urgent hospitalization for chelating agents like EDTA or succimer to prevent long-term harm.

Choice B reason: Monitoring lead levels and providing nutritional counseling (e.g., calcium, iron) are appropriate for lower lead levels (10-20 µg/dL). A level of 48 µg/dL indicates acute toxicity, requiring immediate chelation therapy rather than monitoring alone, as untreated high levels can cause irreversible neurological and developmental damage in young children.

Choice C reason: No treatment is incorrect for a blood lead level of 48 µg/dL, even if asymptomatic. Lead is neurotoxic, causing subtle cognitive and developmental impairments without immediate symptoms. Levels above 45 µg/dL require urgent chelation therapy to prevent long-term brain damage, making this statement inappropriate for management.

Choice D reason: Environmental changes, such as removing lead sources (e.g., paint, water), are critical for preventing further exposure but are insufficient alone for a blood lead level of 48 µg/dL. This level indicates significant toxicity requiring immediate medical intervention like chelation therapy to reduce lead burden and prevent neurological damage.

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A 3-year-old child presents in the pediatric emergency room and is very lethargic. The mother found her in the medication cabinet at home but is unsure what she ingested. What is the nurse’s first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a child in the ER who has been vomiting and needs to calculate maintenance fluids. The child weighs 96.8 lbs. How many milliliters should the nurse administer over 24 hours? What is the hourly rate? Round to the nearest whole number.

Correct Answer is ["83"]

Explanation

A 24-month-old recently had routine lead testing done. A venous sample confirmed a blood lead level of 48 µg/dL. From history and physical exam, the nurse knows that the patient is asymptomatic. What is the best statement from the nurse to the parent regarding management for this patient?

Correct Answer is A

Explanation

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