A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

Remove clothing.

Administer pain medication.

Assess respiratory status.

Insert a Foley catheter.

Answer and Explanation

The Correct Answer is C

A. Remove clothing. Removing clothing is important to prevent further injury from retained heat or chemicals, but it is not the first priority compared to ensuring a patent airway and adequate breathing.
B. Administer pain medication. Pain management is important but comes after ensuring the child's airway and respiratory status are stable.
C. Assess respiratory status. Burns on the face and chest can compromise the airway and breathing. Assessing respiratory status is the first priority to ensure the child’s airway is not obstructed and that they are receiving adequate oxygen.
D. Insert a Foley catheter. Inserting a Foley catheter may be necessary to monitor urine output and assess kidney function in severe burns, but it is not the first priority compared to assessing respiratory status.

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Correct Answer is D

Explanation

A. Percussing ankle and knee reflexes. Safe and non-invasive, and does not risk disturbing the tumor.
B. Assessing for bowel sounds. Routine part of assessment and does not involve manipulating the tumor.
C. Performing range-of-motion exercises on lower extremities. Safe and non-invasive, unrelated to the abdominal tumor.
D. Palpating the abdomen. Palpating the abdomen in a child with Wilms' tumor is avoided to prevent the risk of tumor rupture and subsequent metastasis.

A. "I should not take my regular insulin when I am sick." B. "I will rotate injections sites within my abdominal area." C. "I will test my blood sugar before meals and at bedtime." D. "I should eat a snack before I play soccer."

Correct Answer is A

Explanation

A. "I should not take my regular insulin when I am sick." Regular insulin should not be withheld during illness, as blood glucose levels can increase during times of stress or infection. This statement indicates the child needs further education on managing diabetes during illness.
B. "I will rotate injections sites within my abdominal area." Rotating injection sites within a specific area helps to prevent lipodystrophy and ensures consistent absorption of insulin. This statement shows appropriate understanding.
C. "I will test my blood sugar before meals and at bedtime." Frequent monitoring of blood glucose is essential in managing type 1 diabetes. This statement indicates correct knowledge of monitoring practices.
D. "I should eat a snack before I play soccer." Eating a snack before physical activity helps to prevent hypoglycemia. This statement indicates a proper understanding of diabetes management related to exercise.

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A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which physical assessment technique will the nurse omit when caring for a 2-year-old child diagnosed with Wilms' tumor?

Correct Answer is D

Explanation

A nurse is providing teaching to a school-age child who has a diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?

Correct Answer is A

Explanation

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