A nurse is caring for a child who ingested laundry detergent pods (Tide pods). Which of the following assessments is the nurse's priority?
Respiratory status
Bowel sounds
Burns of the mouth
Visual acuity
The Correct Answer is A
A. Respiratory status is the priority due to the risk of aspiration, chemical pneumonia, or airway swelling, which can be life-threatening.
B. Bowel sounds are relevant but are secondary to airway and respiratory assessment.
C. Burns of the mouth may be present but do not take priority over respiratory assessment.
D. Visual acuity is not an immediate concern in detergent ingestion cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Preferring friends over family can be typical of adolescent development and does not necessarily indicate depression. This suggests the parent may need further education about distinguishing normal adolescent behavior from depression.
B. Significant weight changes can indicate depression in adolescents and should be monitored.
C. Increased sleep can be a symptom of depression in adolescents.
D. Poor academic performance is a possible sign of depression, as it may reflect loss of interest or concentration issues.
Correct Answer is D
Explanation
A. Sedation is not a priority; maintaining adequate oxygenation is critical first.
B. Capillary refill can be assessed but is not an immediate intervention.
C. Sitting upright can aid breathing but does not directly address hypoxia.
D. Administering oxygen helps correct hypoxemia, which is the immediate priority in respiratory distress.
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