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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Bilateral cool extremities can be common after a cardiac catheterization due to transient vasoconstriction but is not necessarily an immediate concern if perfusion remains adequate.
B. Blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not require reporting.
C. Serum glucose of 90 mg/dL is within normal limits for a toddler and does not indicate a complication.
D. Weak pedal pulse distal to the site should be reported because it may indicate arterial occlusion or compromised circulation following the procedure. While pulses may initially be weak due to swelling, they should not be absent or significantly diminished over time.
Correct Answer is B
Explanation
A. A preschool-age child is not expected to give a logical explanation for death. They may not fully understand the concept of death in the same way an older child or adult does.
B. Correct. It is common for preschool-age children to be curious about what happens to the body after death. This curiosity is an age-appropriate response to death.
C. A preschool-age child may not fully grasp the concept of death as permanent. They may have limited understanding of the irreversibility of death.
D. Feeling responsible for a sibling's death would be an inappropriate and potentially concerning response for a preschool-age child. It may indicate a need for further assessment and support.
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