A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

Respiratory Rate

Bowel Sounds

Burns of the mouth

Visual Acuity

Answer and Explanation

The Correct Answer is A

A. Respiratory Rate – Correct. Hydrocarbon poisoning (such as kerosene ingestion) primarily affects the lungs and can lead to aspiration pneumonia, respiratory distress, and chemical pneumonitis.

B. Bowel Sounds – Incorrect. While gastrointestinal effects may occur, they are not the primary concern.

C. Burns of the mouth – Incorrect. Kerosene does not typically cause burns like caustic substances such as acids or alkalis.

D. Visual Acuity – Incorrect. Kerosene does not directly affect vision.

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Correct Answer is D

Explanation

A. Bradycardia, rapid weight gain, and irritability. – Incorrect. Tachycardia (not bradycardia) is more concerning in worsening heart failure.

B. Cough, edema, and increased work of breathing. – Incorrect. These symptoms can occur but are less specific to worsening heart failure in infants.

C. Abdominal pain, poor appetite, and cough. – Incorrect. While appetite changes may occur, abdominal pain is not a classic sign of heart failure in infants.

D. Tachypnea and diaphoresis with feeding, poor weight gain, and irritability. – Correct. Infants with worsening heart failure experience increased respiratory effort, sweating with feeds (due to exertion), failure to thrive, and fussiness due to poor oxygenation.

A. wash the face once a day using hot water. B. Wash the face weekly to avoid irritation, C. Scrub the face three times a day. D. Use pH-balanced skin care products.

Correct Answer is D

Explanation

A. Wash the face once a day using hot water. – Incorrect. Hot water can strip natural oils and worsen irritation. Lukewarm water is recommended.

B. Wash the face weekly to avoid irritation. – Incorrect. Infrequent washing can lead to buildup of oil and bacteria, worsening acne.

C. Scrub the face three times a day. – Incorrect. Excessive scrubbing can irritate the skin and increase inflammation.

D. Use pH-balanced skin care products. – Correct. Mild, pH-balanced cleansers help maintain the skin barrier and reduce acne severity.

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A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

Nursing Test Bank

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