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 B

Explanation

A. "I expect the color of my urine to be amber." Ferrous sulfate does not typically affect the color of urine. This statement indicates a misunderstanding of the medication's effects.
B. "I will expect dark, tarry stools." Ferrous sulfate can cause stools to become dark or black, which is a common and expected side effect due to the iron content. This indicates the client understands a normal side effect of the medication.
C. "I will not get as many infections." Ferrous sulfate is used to treat iron deficiency anemia and does not directly influence the incidence of infections. This indicates a lack of understanding of the medication’s purpose.
D. "I will take extra care to protect against increased bruising." Increased bruising is not associated with ferrous sulfate. This indicates a misunderstanding of the medication's side effects.

A. Maintain a saline-lock. B. Educate the parents about potential complications. C. Place the child on a no-salt-added diet. D. Check the child's weight daily.

Correct Answer is D

Explanation

A. Maintain a saline-lock.Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
C. A no-salt-added diet is important to help manage fluid retention and hypertension, which are common in acute glomerulonephritis. However, while important, it does not take immediate priority over assessing the child's fluid status.
D. Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.

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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 reinforcing teaching with a client who is prescribed ferrous sulfate. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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