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 A

Explanation

A. Projectile vomiting after feedings: Projectile vomiting after feedings, especially occurring a short time after feeding, is a classic sign of pyloric stenosis due to obstruction at the pylorus.
B. Absent bowel sounds: Absent bowel sounds may occur in more advanced cases of bowel obstruction but are not specific to pyloric stenosis.
C. Increased sodium level: Increased sodium level is not typically associated with pyloric stenosis.
D. Golf ball-size mass over the left quadrant: A palpable mass in the left quadrant is not a typical finding in pyloric stenosis.

A. Rigid abdomen B. Ribbonlike, foul-smelling stools C. Projectile vomiting D. Chronic hunger

Correct Answer is B

Explanation

A. Rigid abdomen: A rigid abdomen is not typically associated with Hirschsprung disease unless there is severe obstruction and distension.
B. Ribbonlike, foul-smelling stools: Hirschsprung disease causes obstruction of the colon, leading to constipation and ribbonlike, foul-smelling stools proximal to the affected segment.
C. Projectile vomiting: Projectile vomiting is not typically associated with Hirschsprung disease but may occur in other conditions causing bowel obstruction.
D. Chronic hunger: Chronic hunger is not a typical finding in Hirschsprung disease and is more indicative of metabolic or endocrine disorders.

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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

A nurse is collecting data from an infant. Which of the following is a clinical manifestation of pyloric stenosis?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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