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

Answer and Explanation

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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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.

A. Administer methylprednisolone. B. Administer oxygen. C. Administer epinephrine. D. Administer a nebulized bronchodilator.

Correct Answer is C

Explanation

A. Methylprednisolone is a corticosteroid that can help reduce inflammation. While it may be beneficial in some cases of allergic reactions, it is not the first-line treatment for severe
anaphylaxis. In this situation, the priority is to address the immediate symptoms and stabilize the child's condition.

B. Administering oxygen is an important intervention, especially if the child is experiencing respiratory distress. However, in the case of severe anaphylaxis, administering epinephrine is the highest priority as it addresses multiple aspects of the reaction, including airway constriction,
low blood pressure, and hives.

C. This is the correct action. Epinephrine is the first-line treatment for anaphylaxis. It works rapidly to improve breathing, increase blood pressure, and reduce allergic symptoms. It is considered the most critical intervention in this situation.

D. Nebulized bronchodilators can be beneficial for respiratory distress, but they are not the first-line treatment for severe anaphylaxis. Epinephrine is more effective in rapidly reversing the
allergic reaction and stabilizing the child's condition. It addresses a broader range of symptoms in anaphylaxis compared to a bronchodilator.

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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.)

Nursing Test Bank

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Correct Answer is C

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