A nurse in an urgent care clinic is caring for a school-age child who has injuries resulting from physical maltreatment. Which of the following actions should the nurse take first?

Ensure the child's safety.

Tell the child they are not at fault.

Document the location of the child’s injuries

Notify local law enforcement.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Ensuring the child's safety is the top priority. If the child is in immediate danger, steps must be taken to protect them.

Choice B reason:

While providing emotional support to the child is important, ensuring their physical safety takes precedence.

Choice C reason:

Documenting injuries is important for a comprehensive assessment and for legal purposes, but it should follow ensuring the child's immediate safety.

Choice D reason:

Notifying law enforcement may be necessary, but ensuring the child's immediate safety comes first.

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Correct Answer is B

Explanation

Choice A reason:

Cold compresses may exacerbate vaso-occlusion in a client with sickle cell anemia and are not recommended.

Choice B reason:

Maintaining bed rest can help reduce the risk of hypoxemia, as it minimizes energy expenditure and oxygen demand.

Choice C reason:

Increasing oral fluid intake is important for preventing vaso-occlusive crises, so decreasing fluid intake is not a recommended intervention.

Choice D reason:

Administering meperidine for fever is not a standard intervention for sickle cell anemia. Fever during a vaso-occlusive crisis should be evaluated and treated according to the underlying cause.

A. Apply suction in 3 to 4 second increments. B. Use clean technique when performing suctioning. C. Select a catheter that fits snugly into the tracheostomy tube. D. Instill 2 mL of 0.9% sodium chloride prior to suctioning.

Correct Answer is A

Explanation

Choice A reason:

When suctioning a tracheostomy tube, it's important to limit the suctioning time to 3 to 4 seconds to avoid hypoxia and trauma to the airway.

Choice B reason:

Sterile technique, not clean technique, is used when performing tracheostomy suctioning to prevent infection.

Choice C reason:

The catheter should be sized appropriately for the tracheostomy tube, but it should not fit too snugly to avoid causing trauma to the airway.

Choice D reason:

Instilling saline prior to suctioning is not recommended as it can lead to complications, including aspiration and increased risk of infection.

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A nurse in an urgent care clinic is caring for a school-age child who has injuries resulting from physical maltreatment. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is preparing to perform suctioning for an infant who has a partial mucus occlusion of her tracheostomy tube. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

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