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 ["B","C","E"]
Explanation
This laboratory test can contribute to confirming a diagnosis of rheumatic fever.
Choice A is wrong because Blood urea nitrogen (BUN) is not used to diagnose rheumatic fever.
Choice D is wrong because Partial thromboplastin time (PTT) is not used to diagnose rheumatic fever.
Correct Answer is A
Explanation
After an arterial cardiac catheterization, the patient will need to keep their leg straight for several hours following the procedure to prevent bleeding from the catheter insertion site.
Choice B is wrong because droplet isolation precautions are not necessary after an arterial cardiac catheterization.
Choice C is wrong because assisting the child into a supine position may not be necessary and could be uncomfortable for the child.
Choice D is wrong because checking oxygen saturation every 4 hours may not be frequent enough for a child who has undergone an arterial cardiaccatheterization and may require more frequent monitoring of oxygen saturation.
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