updated
1. When the nurse is caring
a. Perform a primary assessment
for a child presenting
with a trau- matic injury, Explanation:
which action is priority? The nurse would perform a primary assessment.
When as- sessing a child with a traumatic injury, airway
a. Perform a primary
(A), breathing (B), and circulation (C) are assessed first:
assess- ment
assess the patency of the airway and establish the
b. Notify the primary
ettectiveness of breathing, examining the child's
health care provider respiratory ettort, breath sounds, and color;
evaluate the circulation, noting pulse rate and quali-
c. Ensure the code cart is avail- ty and observing the color, skin temperature, and
perfusion.
able Once this is accomplished, the nurse would notify the
d. Apply an oxygen health care provider and apply monitors as needed.
saturation monitor The nurse should ensure a code cart is available
before the start of the shift.
2. A 13-year-old adolescent
has had a near-drowning a. Administer 100% oxygen by mask.
experi- ence. The nurse
notices the client has Explanation:
labored breathing Management of the near-drowning victim focuses on
assess-
and a cough. What is the prior- ing the client's airway, breathing, and circulation
(ABCs) and
ity intervention? c. Check the client's capillary
refill time.
a. Administer 100% d. Perform postural drainage
oxygen by mask. every hour.
b. Have the client sit
up straight in a 3. Which assessment finding
chair. would indicate to the health
,Ricci CH 51 questions and answers graded A+
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correcting hypoxemia. Administering
oxygen is the primary intervention to assist
breathing. It is best to let the adolescent
assume the most comfortable position for
him or her. Checking capillary refill time helps
determine inettective tissue perfu- sion, but it
does not provide an intervention for the
labored breathing. Postural drainage
techniques to remove water from the lungs
are of no proven value in a near-drowning
experi- ence.
c. Breath sounds are heard over the
abdominal area.
,Ricci CH 51 questions and answers graded A+
updated
care team that a child Explanation:
would need to be Indications the tube is accidentally inserted into the
reintubated due to esopha-
improper placement of the en- gus include auscultation of breath sounds over
the abdominal
dotracheal region. Indications the tracheal tube is correctly placed
tube? include symmetrical chest rise, water vapor on the
inside of the tube,
a. Symmetrical chest rise is ob- and a rise in oxygen saturation.
served.
b. There's water vapor on
the inside of the tube.
c. Breath sounds are
heard over the
abdominal area.
d. Oxygen saturation
rises from 78% to 93%
after intuba- tion.
4. A 12-year-old boy has broken b. Establish a suitable IV site.
his arm and is showing signs
and symptoms of shock. Which Explanation:
action should the nurse The goal of treating shock is to restore circulating
take first? blood vol- ume. This requires that vascular access be
obtained to ad- minister fluids and vasoactive drugs.
a. Begin hyperventilation. Hyperventilation is re- served for temporary treatment
b. Establish a suitable IV of severe intracranial pressure. Analgesics should not
site. be administered prior to neurologic
c.Provide oral analgesics as or- and cardiovascular examination being performed.
Chelation
dered. d. Draw blood for type and
, Ricci CH 51 questions and answers graded A+
updated
cross-match. therapy is a treatment for metallic poisoning.
5. A child is exhibiting symp-
tomatic bradycardia that
has been unresponsive to a. atro
ventila-
pine
Explanation
:
tion and oxygenation. Which of Atropine is used for symptomatic bradycardia
unresponsive
to ventilation and oxygenation. Sodium bicarbonate is used