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 D

A. Increased restlessness can be a normal response to pain and discomfort in a toddler
with a burn injury. It is important to address pain management, but this finding alone may not require immediate reporting to the provider.

B. A respiratory rate of 25 breaths per minute is within the normal range for a toddler. It does not require immediate reporting to the provider.

C. Bowel sounds of 20 per minute are within the normal range for a toddler. It does not require immediate reporting to the provider.

D. A urinary output of 35 mL/hr is lower than the expected urine output for a toddler. In a child of this weight, the expected urine output is typically higher. This finding may
indicate decreased renal perfusion, which should be reported to the provider for further evaluation.

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Correct Answer is A

Explanation

A. Teaching the client about ostomy care is important if the Meckel diverticulum was removed and an ostomy was created as part of the surgical procedure.

B. Total parenteral nutrition is not typically indicated following the repair of Meckel diverticulum. Most clients can resume oral intake shortly after surgery.

C. Long-term antibiotic therapy is not typically necessary after the repair of Meckel diverticulum unless there are specific indications for ongoing treatment.

D. Maintaining an NG (nasogastric) tube for decompression is not typically indicated after the repair of Meckel diverticulum. It may be used temporarily if there are concerns about bowel obstruction or ileus, but it is not a long-term intervention.

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?

Nursing Test Bank

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