A nurse in an emergency department is assessing a school-age child who was brought in by their parents and has scald burns to both hands and wrists. The nurse suspects physical abuse.
Which of the following actions should the nurse take?
Discuss the suspicion of physical abuse with the provider.
Confront the parents with the suspicion of physical abuse.
Ask the hospital security to detain and question the parents.
Contact Child Protective Services.
The Correct Answer is D
- A. Discussing the suspicion of physical abuse with the provider is the appropriate action for the nurse to take. However, this should be done after the matter is reported to child protection services.
- B. Confronting the parents with the suspicion of physical abuse is not an appropriate action for the nurse to take, as it can escalate the situation and endanger the child or the nurse.
- C. Asking the hospital security to detain and question the parents is not an appropriate action for the nurse to take, as it violates the parents' rights and may interfere with the legal process.
- D.Contacting Child Protective Services is appropriate action for the nurse to take at this point as it is the nurse's legal responsibility to do so.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Hanging the transfusion with dextrose 5% in 0.9% sodium chloride is incorrect. Packed red blood cells (PRBCs) are transfused with normal saline (0.9% sodium chloride) and not with dextrose-containing solutions. Using dextrose can cause the red blood cells to hemolyze.
Choice B rationale:
Infusing the transfusion over 5 hours is incorrect. PRBC transfusions are typically administered over 2-4 hours, not 5 hours. Infusing the blood too slowly may cause the patient discomfort and may also increase the risk of bacterial growth in the blood product.
Choice C rationale:
Using a 20-gauge IV catheter to transfuse the blood is incorrect. While a 20-gauge IV catheter is suitable for most blood transfusions, it may not be appropriate for older adults or patients with fragile veins. A smaller gauge, such as 22 or 24, might be more suitable to prevent phlebitis and ensure a steady flow without damaging the blood cells.
Choice D rationale:
Monitoring vital signs every hour throughout the transfusion is the correct action. During a blood transfusion, it's crucial to monitor the patient's vital signs frequently to detect any adverse reactions promptly. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, should be assessed before the transfusion, 15 minutes after starting the transfusion, and then hourly thereafter. This vigilant monitoring helps in identifying potential transfusion reactions, such as fever, chills, or hypotension, allowing for immediate intervention if needed.
Correct Answer is {"dropdown-group-1":"A"}
Explanation
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