A nurse is caring for a child who received partial -thickness burn s to over 50% of his body 10 days ago and has splints over his joints to prevent contractures.
Which of the following action should the nurse take? (select all that apply.).
provide a high-calories diet
Administer analgesics IM.
monitor intake and output
remove splints during sleep.
change dressing using aseptic technique.
Correct Answer : A,C,E
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Pinpoint pupils are not a typical finding in an adolescent who has inhaled gasoline. Pinpoint pupils are more commonly associated with opioid use.
Choice B rationale
Hypothermia is not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Choice C rationale
Ataxia, or lack of muscle coordination, can occur after inhaling gasoline. The gasoline vapors can depress the central nervous system, leading to symptoms such as dizziness, confusion, and ataxia.
Choice D rationale
Hyperactive reflexes are not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Correct Answer is B
Explanation
Choice A rationale
Brisk capillary refill is a normal finding and does not require intervention.
Choice B rationale
Tachypnea, or rapid breathing, is a common symptom of respiratory syncytial virus (RSV) infection in infants. It can indicate that the infant is having difficulty breathing and needs immediate intervention.
Choice C rationale
Rhinorrhea, or a runny nose, is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
Choice D rationale
Coughing is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.
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