A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body.
Which of the following findings should the nurse report to the provider?
Increased restlessness
Respiratory rate 25/min
Bowel sounds 20/min
Urinary output 35 mL/hr
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: Increased restlessness in a toddler with a full-thickness burn may indicate hypoxia, pain, or shock. These conditions require immediate medical attention to prevent further complications and ensure proper management of the burn injury.
Choice B rationale: A respiratory rate of 25/min is within the normal range for toddlers (20-30 breaths per minute). This finding does not indicate an immediate concern that requires reporting to the provider.
Choice C rationale: Bowel sounds of 20/min are within the normal range (5-30 sounds per minute). This finding does not indicate any gastrointestinal complications that need to be reported to the provider.
Choice D rationale: Urinary output of 35 mL/hr is within the normal range for toddlers (1-2 mL/kg/hr). This finding indicates adequate kidney function and hydration status, so it does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Prolonged headache is not typically identified as a common trigger for seizures. While headaches can be associated with certain types of seizures, they are not generally considered a trigger for seizure activity.
Choice B rationale
Decreased temperature, or hypothermia, is not typically identified as a common trigger for seizures. In fact, fever or increased body temperature is more commonly associated with triggering seizures, particularly in children.
Choice C rationale
Lack of sleep is a well-recognized trigger for seizures. Sleep deprivation can lead to increased seizure frequency in individuals with epilepsy. Ensuring adequate sleep is an important part of managing seizure disorders.
Choice D rationale
Exposure to second-hand smoke is not typically identified as a common trigger for seizures. While it is generally harmful to health, it is not specifically associated with an increased risk of seizures.
Correct Answer is B
Explanation
Choice A rationale
Bacterial vaginosis and trichomoniasis are both sexually transmitted infections, but they are not nationally notifiable, meaning cases are not required to be reported to the Centers for Disease Control and Prevention.
Choice B rationale
Gonorrhea is a nationally notifiable sexually transmitted infection. This means that confirmed and probable cases are required to be reported to the Centers for Disease Control and Prevention.
Choice C rationale
Human Papilloma Virus (HPV) is a common sexually transmitted infection, but it is not nationally notifiable.
Choice D rationale
Genital Herpes Simplex Virus is a common sexually transmitted infection, but it is not nationally notifiable.
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