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 C
Explanation
A. Minimizing movement of the limbs is not a recommended action during a seizure. It is important to allow the seizure to run its course while ensuring the safety of the child.
B. Placing the child in a prone position is not recommended during a seizure. The child should be placed in a lateral (side-lying) position to help prevent aspiration and maintain an open airway.
C. This is the correct action. Clearing the area of hard objects helps prevent injury to the child during the seizure. It is important to create a safe environment.
D. Inserting a tongue blade between the teeth is not recommended. This action can cause injury to the child's mouth or teeth. It is a myth that individuals can swallow their tongue during a seizure.
Correct Answer is B
Explanation
A. An adolescent in skin traction reporting a pain level of 7 requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
B. This client should be assessed first. Slurred speech in an adolescent with sickle cell anemia is a potential sign of a cerebral event, such as a stroke or a transient ischemic attack (TIA), and requires immediate evaluation.
C. The toddler with a new diagnosis of osteomyelitis requiring an IV bolus of nafcillin should be assessed promptly, but this is not as urgent as the potential neurological symptom described in option B.
D. The toddler with a partial-thickness burn on the right hand requiring a dressing change also requires attention, but it is not as immediately concerning as the potential neurological symptom described in option B.
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