A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury.
Which of the following actions should the nurse take first?
Assess respiratory status.
Inspect for fluid leaking from the ears.
Examine the scalp for lacerations.
Check pupil reactions.
The Correct Answer is A
The first action the nurse should take is to assess the respiratory status of the infant.
After a head injury, it is important to ensure that the child’s airway is clear and that they are breathing adequately.
This is a crucial step in providing care for a patient with a head injury.
Choice B is wrong because inspecting for fluid leaking from the ears is not the first priority.
Choice C is wrong because examining the scalp for lacerations is not the first priority.
Choice D is wrong because checking pupil reactions is not the first priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A 24-gauge catheter is the smallest-gauge catheter and is appropriate for administering IV fluids and medications to an infant.
Choice B is wrong because an opaque dressing would prevent the nurse from visualizing the insertion site.
Choice C is wrong because starting an IV in an infant’s foot can be painful and difficult to secure.
Choice D is wrong because IV sites should be changed every 72-96 hours or according to facility policy.
Correct Answer is B
Explanation
Deep-breathing and counting exercises can help the child relax and cope with anxiety before the procedure.
Choice A is wrong because a 30-minute teaching session may not be necessary or appropriate for a school-age child.
Choice C is wrong because it’s important to use clear and honest language when explaining the procedure to the child.
Choice D is wrong because it’s important to explain the procedure to the child in a calm and quiet environment, not in the playroom.
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