A nurse in the emergency department is caring for a school-age child who has developed respiratory stridor, wheezing and urticaria after receiving an IV medication.
Which of the following actions should the nurse take first?

Choice A rationale

Providing a high-calorie diet is a recommended action for a child who has received partial-thickness burns to

over 50% of his body. After a burn injury, the body needs extra calories and protein to heal, fight infection, and maintain its functions. A high-calorie diet can help meet these increased nutritional needs.

Choice B rationale

Administering analgesics intramuscularly (IM) is not a recommended action for a child with partial- thickness burns. Pain management is crucial in burn care, but analgesics should be given orally or intravenously, not IM, to avoid additional pain and tissue damage.

Choice C rationale

Monitoring intake and output is a recommended action for a child who has received partial-thickness burns to over 50% of his body. This can help assess the child’s hydration status, kidney function, and response to fluid replacement therapy.

Choice D rationale

Removing splints during sleep is not a recommended action for a child with partial-thickness burns. Splints are used to prevent contractures by keeping the joints in a functional position. They should be worn as prescribed by the healthcare provider, which often includes during sleep.

Choice E rationale

Changing dressings using aseptic technique is a recommended action for a child who has received partial- thickness burns to over 50% of his body. This can help prevent infection, promote healing, and assess the burn’s progress.

Choice A rationale

Encouraging flexion and extension of the neck in a client with a halo vest for cervical vertebral fracture is not recommended. The purpose of the halo vest is to immobilize the neck to allow healing.

Choice B rationale

Assessing the pin sites for infection once every other day is not typically recommended. More frequent assessments are usually necessary to promptly identify any signs of infection.

Choice C rationale

Repositioning the client using a turning sheet is the correct action. This method of repositioning can help to prevent skin breakdown and pressure ulcers, which are potential complications for clients who are immobilized.

Choice D rationale

Tightening the screw on the halo device once-quarter turn every 48 hours is not typically recommended. Adjustments to the halo device should be made by a healthcare professional as needed based on the client’s condition and comfort.