A mother rushes into the emergency department carrying her toddler who has been exposed to some cleaning products.
The child has a chemical smell on their hands, face, and clothes.
After ensuring the airway is patent, which action should the nurse take first?
Obtain equipment for gastric lavage.
Determine the type of chemical exposure.
Assess the child for altered sensorium.
Call the poison control emergency number.
The Correct Answer is B
Choice A rationale
Gastric lavage is a procedure that involves the insertion of a tube into the stomach to remove its contents and is typically used in cases of poisoning or drug overdose. However, it should not be the first action taken. The type of chemical exposure needs to be determined first to guide appropriate treatment.
Choice B rationale
Determining the type of chemical exposure is crucial as it guides the subsequent steps in management. Different chemicals can have different effects on the body and require different treatments.
Choice C rationale
While assessing for altered sensorium is important in a child exposed to chemicals, it is not the first action. The nurse needs to identify the type of chemical the child was exposed to in order to anticipate potential complications and guide treatment.
Choice D rationale
Calling the poison control emergency number is an important step in managing a case of chemical exposure. However, having information about the type of chemical the child was exposed to can make this call more effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While monitoring serum sodium levels is important in a client with DKA, it is not the most critical. Hyperglycemia can lead to a state of effective osmotic diuresis, which can cause sodium depletion.
Choice B rationale
Serum potassium levels are crucial to monitor in a client with DKA3. Despite total body potassium depletion, serum potassium levels may be high or normal upon presentation due to acidosis and insulin deficiency. However, with insulin treatment, potassium will shift back into the cells, potentially leading to life-threatening hypokalemia.
Choice C rationale
Blood urea nitrogen (BUN) might be elevated due to dehydration, but it is not the most critical lab value to monitor in the management of DKA3.
Choice D rationale
Urine ketones are not as important to monitor as serum potassium in DKA. The presence of ketones in urine only confirms that the body is breaking down fat, not the severity of DKA3.
Correct Answer is C
Explanation
Choice A rationale
Monitoring capillary refill distal to the infusion site is a general nursing intervention during IV therapy. However, it is not specific to the administration of a vesicant chemotherapeutic agent.
Choice B rationale
Applying a topical anesthetic at the infusion site for burning is not a standard intervention during the administration of a vesicant chemotherapeutic agent. The burning sensation is not due to the IV site but due to the vesicant agent itself.
Choice C rationale
Assessing the IV site frequently for signs of extravasation is the most appropriate intervention during the administration of a vesicant chemotherapeutic agent. Extravasation, the leakage of the vesicant into the surrounding tissue, can cause severe local tissue damage. Early detection and intervention are crucial to minimize harm.
Choice D rationale
While it is important to explain potential side effects to the client, explaining that temporary burning at the IV site may occur is not the most crucial intervention. The priority is to monitor for and prevent extravasation.
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