A nurse is caring for a child who received partial-thickness burns to over 50% of his body 10 days ago and has splints over his joints to prevent contractures. Which of the following actions should the nurse take? (Select all that apply.)
Provide a high-calorie det
Monitor intake and output.
Change dressings using aseptic technique
Remove splints during sleep
Administer analgesics IM
Correct Answer : A,B,C
A. Providing a high-calorie diet is important for a child with extensive burns to support wound healing and recovery.
B. Monitoring intake and output is crucial to assess fluid balance and ensure that the child is receiving enough fluids and nutrients for healing.
C. Changing dressings using an aseptic technique helps prevent infection, which is a significant risk in burn wounds.
D. Removing splints during sleep is not recommended, as they are in place to prevent contractures. They should be worn consistently, including during sleep.
E. Administering analgesics IM (intramuscularly) is not typically indicated. Pain
management can be achieved through various routes, and IM administration may not be necessary. Additionally, it's important to consider the child's pain level and choose the most appropriate and effective route for analgesia.
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Related Questions
Correct Answer is D
Explanation
A. Increased restlessness can be a normal response to pain and discomfort in a toddler
with a burn injury. It is important to address pain management, but this finding alone may not require immediate reporting to the provider.
B. A respiratory rate of 25 breaths per minute is within the normal range for a toddler. It does not require immediate reporting to the provider.
C. Bowel sounds of 20 per minute are within the normal range for a toddler. It does not require immediate reporting to the provider.
D. A urinary output of 35 mL/hr is lower than the expected urine output for a toddler. In a child of this weight, the expected urine output is typically higher. This finding may
indicate decreased renal perfusion, which should be reported to the provider for further evaluation.
Correct Answer is A
Explanation
A. Increased expectoration (coughing up mucus) indicates that the chest physiotherapy treatments have been effective in helping to clear the airways of mucus, which is a common goal in managing cystic fibrosis.
B. Increased urine output is not a direct indicator of the effectiveness of chest physiotherapy in managing cystic fibrosis.
C. Increased heart rate is not a specific indicator of the effectiveness of chest physiotherapy in managing cystic fibrosis. In fact, an increased heart rate may indicate stress or discomfort.
D. Reduced pain is a positive outcome but may not be directly related to the effectiveness of chest physiotherapy in managing cystic fibrosis. The primary goal of chest physiotherapy is to improve airway clearance.
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