The poison control nurse receives a call from the caregiver of a young school age child who may have ingested a poisonous substance. Which is the priority response by the nurse?
What do you think that the child might have ingested?’
’At what time did the child ingest the substance?'
‘Induce vomiting while you wait for emergency personnel to arrive.'
‘Check breathing and heart rate.’
The Correct Answer is A
In case of suspected ingestion of a poisonous substance, the priority response of the poison control nurse should be to assess the child's vital signs, especially breathing and heart rate, to determine if the child is experiencing any immediate life-threatening symptoms. This information will help the nurse determine the appropriate course of action, such as whether to instruct the caregiver to perform CPR or to immediately call for emergency medical assistance.
Asking about the substance ingested and the time of ingestion are also important pieces of information to gather, but they should not take priority over assessing the child's vital signs. Inducing vomiting is generally not recommended unless instructed to do so by a medical professional, as it can cause further harm if the substance ingested is corrosive or caustic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Booster seats are recommended for children between the ages of 4 and 8, or until they are 4'9" tall. This is because seat belts are designed for adults and may not properly fit a child's smaller body. A booster seat helps to position the seat belt correctly on the child's body, improving the effectiveness of the seat belt and reducing the risk of injury in the event of a crash.
Option a is incorrect because 10 years old is too old to need a car seat. Option b is incorrect because children under the age of 8, or under 4'9" tall, should not use a seat belt alone. Option d is incorrect because car seats are recommended until children are at least 4 years old, not 3.
Correct Answer is A
Explanation
Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.
Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.
While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.
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