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","C","D"]

Explanation

A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.

A. Collect a blood sample for hemoglobin Alc. B. Give the client a glass of orange juice. C. Notify the healthcare provider. D. Assess client for polyuria and polyphagia.

Correct Answer is B

Explanation

In this situation, the client has a fingerstick glucose level of 35 mg/dL (1.94 mmol/L) and is alert but diaphoretic. The charge nurse should take the following action:

Give the client a glass of orange juice.

A glucose level of 35 mg/dL (1.94 mmol/L) is considered significantly low (hypoglycemia), and the client's symptoms of diaphoresis indicate that the low glucose level is likely causing the symptoms. Providing the client with a glass of orange juice or another source of fast-acting carbohydrate is appropriate to quickly raise the blood sugar level and alleviate the symptoms of hypoglycemia.

Collecting a blood sample for hemoglobin A1c (HbA1c) is not necessary in this acute situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is used to assess long-term glycemic control in clients with diabetes. It does not provide immediate information or guide immediate interventions for acute hypoglycemia.

Notifying the healthcare provider is not the first action to take in this situation. The client's low glucose level can be promptly addressed by administering a source of fast-acting carbohydrate, such as orange juice. If the client's symptoms persist or worsen despite appropriate intervention, or if there are other concerning factors, then notifying the healthcare provider would be appropriate.

Assessing the client for polyuria (excessive urination) and polyphagia (excessive hunger) is important in the overall management of diabetes, but it is not the immediate action to take in this acute situation of hypoglycemia. The priority at this time is to address the low blood sugar level and relieve the client's symptoms.

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

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Naxlex Comprehensive Predictor Exams

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Correct Answer is B

Explanation

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

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Exhibits The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take?

Review H and P and nurse's notes.

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