Review H and P and nurse's notes.

What are the first four actions that the nurse should take?

Take the child's pulse

Place a cervical collar on the client

Look for any open wounds

Call child protective services

Determine if the child's airway is clear

Start a peripheral intravenous line

Answer and Explanation

Correct Answer : A,B,C,E

A)   Correct- Assessing the child's pulse helps determine their cardiac status and whether they have a detectable heartbeat. This information is essential for deciding the appropriate interventions.
B)   Correct- Placing a cervical collar is necessary if there is any suspicion of cervical spine injury due to the fall or submersion. This action helps stabilize the neck and prevent further damage to the spine.
C)   Correct- Checking for open wounds is important to assess for potential sources of bleeding or infection that may require immediate attention.
D)   Incorrect- While child safety is important, the immediate priority in this situation is assessing and stabilizing the child's medical condition. Child protective services may be involved later if there are concerns about the circumstances surrounding the incident.
E)   Correct- Assessing the airway is of utmost importance to ensure that the child can breathe. In cases of near-drowning, ensuring a clear airway is crucial for oxygenation.
F)   Incorrect- While establishing intravenous access may be important for certain interventions, it is not one of the immediate priorities in this situation. Ensuring the child's airway, breathing, and circulation take precedence.

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Correct Answer is B

Explanation

After retinal detachment surgery, it is crucial to protect the eye and the surgical repair site from accidental trauma or pressure. Providing an eye shield helps to shield the eye during sleep when the client may not have conscious control over their movements.

This can help prevent inadvertent rubbing or bumping of the eye, which could potentially disrupt the surgical repair and hinder the healing process.

Obtaining vital signs every 2 hours during hospitalization is a routine nursing intervention for postoperative care in general but is not specific to retinal detachment surgery. The frequency of vital sign monitoring may vary depending on the client's overall condition and the healthcare provider's orders.

Teaching a family member to administer eye drops may be necessary for the client's ongoing care, but it is not specifically related to the immediate postoperative period. Eye drop administration instructions can be provided as part of the client's discharge teaching.

Encouraging deep breathing and coughing exercises is a general postoperative intervention that promotes respiratory function and helps prevent complications such as pneumonia. While important for overall postoperative care, it is not specific to retinal detachment surgery.

A. Review the literature and answer any questions the nurse is able to answer. B. Determine their reasoning for seeking genetic counseling at this time. C. Tell the couple that it is best to call the counselor with their questions. D. Recommend a community support group for parents of children with Trisomy 21.

Correct Answer is A

Explanation

A) Correct- As a nurse, it's important to provide accurate and helpful information to patients and families. In this situation, the parents have brought literature from a genetic counselor and are seeking clarification. The nurse should review the literature to the best of their ability and answer any questions they can. This approach demonstrates support, a willingness to help, and a commitment to providing accurate information.
B) Incorrect- While understanding the parents' reasons for seeking genetic counseling is important, it shouldn't be the first response when they have already brought literature and are seeking clarification. Addressing their questions and concerns is the immediate priority.
C) Incorrect- While it's true that the couple could contact the genetic counselor for further information, as a healthcare professional, the nurse should still offer assistance by reviewing the literature and answering questions to the best of their ability.
D) Incorrect- While support groups can be beneficial for parents of children with Trisomy 21, the immediate concern is addressing the parents' questions about the literature they've brought. Providing accurate information should be the primary focus at this time.

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Review H and P and nurse's notes. What are the first four actions that the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

The healthcare provider prescribes dopamine 2 mcg/kg/min intravenously (IV) for client who weighs 60 kg. The IV bag contains dopamine 200 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse?

The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern?

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

Review H and P and nurse's notes.

What are the first four actions that the nurse should take?