A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full-thickness burn to 10% of his 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

Answer and Explanation

The Correct Answer is A

A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.

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Correct Answer is ["A","B","C"]

Explanation

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.

A. Abrasions on the knees B. Front deciduous teeth missing C. Weight in 45th percentile D. Bruising around the wrists

Correct Answer is D

Explanation

A. Abrasions on the knees may be common in active children and may not necessarily indicate physical abuse.

B. Front deciduous teeth missing is a normal occurrence as children lose their baby teeth and grow permanent teeth. It is not indicative of physical abuse.

C. Weight in the 45th percentile indicates that the child's weight falls within the average range for their age. This finding is not indicative of physical abuse.

D. Bruising around the wrists can be a concerning sign, especially if it suggests that the child has been restrained or grabbed forcefully. This finding raises suspicion of physical abuse and should be further assessed and reported if necessary.

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A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full-thickness burn to 10% of his body. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["A","B","C"]

Explanation

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