A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?
Respiratory Rate
Bowel Sounds
Burns of the mouth
Visual Acuity
The Correct Answer is A
A. Respiratory Rate – Correct. Hydrocarbon poisoning (such as kerosene ingestion) primarily affects the lungs and can lead to aspiration pneumonia, respiratory distress, and chemical pneumonitis.
B. Bowel Sounds – Incorrect. While gastrointestinal effects may occur, they are not the primary concern.
C. Burns of the mouth – Incorrect. Kerosene does not typically cause burns like caustic substances such as acids or alkalis.
D. Visual Acuity – Incorrect. Kerosene does not directly affect vision.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Low systolic blood pressure in the upper extremities and elevated systolic blood pressure in the lower extremities. – Incorrect. Coarctation of the aorta causes the opposite finding.
B. Elevated systolic blood pressure in the upper extremities and elevated systolic blood pressure in the lower extremities. – Incorrect. Blood pressure in the lower extremities is reduced due to decreased blood flow.
C. Low systolic blood pressure in the upper extremities and low systolic blood pressure in the lower extremities. – Incorrect. Coarctation of the aorta leads to hypertension in the upper body due to increased resistance.
D. Elevated systolic blood pressure in the upper extremities and low systolic blood pressure in the lower extremities. – Correct. Coarctation of the aorta causes high BP in the arms and low BP in the legs due to obstructed blood flow past the narrowing.
Correct Answer is C
Explanation
A. Facilitate proper feeding and swallowing in the infant. – Incorrect. Feeding modifications are needed, but elbow restraints do not assist with swallowing.
B. Promote comfort and relaxation in the infant. – Incorrect. Restraints prevent disruption of the surgical site but do not specifically provide comfort.
C. Prevent the infant from injuring the repair site. – Correct. Elbow restraints prevent the infant from touching or rubbing the surgical site, reducing the risk of wound dehiscence.
D. Encourage the infant to use their arms and hands for exploration. – Incorrect. The purpose of the restraints is to limit arm movement, not promote exploration.
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