Exhibits
Review H and P and nurse's note.
Which are the first four actions that the practical nurse (PN) should do?
Take the child's pulse
Place a cervical collar on the client
Call child protective services
Start a peripheral IV line
Look for any open wounds
Determine if the child's airway is clear
The Correct Answer is A, F, E
A. Take the child's pulse
Assessing the pulse is crucial to determine if the child has a heartbeat and to evaluate the effectiveness of CPR. This helps to determine the current cardiovascular status of the child and the urgency of further resuscitation efforts.
F. Determine if the child's airway is clear
Ensuring a clear airway is a priority in any emergency situation. A blocked airway can prevent effective ventilation and oxygenation, which is critical for a child who has experienced a near-drowning incident.
D. Start a peripheral IV line
Starting a peripheral IV line is important for administering fluids and medications that may be necessary for resuscitation and stabilization. It allows for rapid access to the child's circulatory system for necessary interventions.
E. Look for any open wounds
Checking for open wounds is necessary to identify any immediate sources of bleeding or potential infections that need to be addressed. It is part of a thorough initial assessment to ensure comprehensive care for the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A client who needs to ambulate for the first time since delivery requires the PN’s immediate attention to ensure safety and prevent complications such as orthostatic hypotension or falls.
B. A client prepared for discharge who has a question about teaching is important but does not take precedence over immediate safety concerns related to the client’s physical activity.
C. A tired client with twins who would like her babies returned to the nursery is important for the client’s well-being, but it is not as urgent as ensuring the safety of a postpartum client beginning to ambulate.
D. Removing indwelling urinary and intravenous catheters is important but not as urgent as ensuring the safety of a client ambulating for the first time after birth.
Correct Answer is B
Explanation
A. Exhaling slowly after two seconds is not part of the incentive spirometer use. Proper technique involves a slow, steady inhalation, not exhalation.
B. Blowing forcefully into the mouthpiece indicates incorrect use of the spirometer. The client should inhale slowly and deeply through the mouthpiece to expand the lungs and improve ventilation.
C. Using a tight seal around the mouthpiece is correct and necessary to ensure that the spirometer measures the volume of air accurately.
D. Sitting upright during the treatment is correct as it maximizes lung expansion and facilitates deep breathing.
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