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
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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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 D
Explanation
A. WBC count 15,000/mm3 is elevated, which may indicate ongoing leukemia activity. It does not necessarily indicate a therapeutic effect.
B. RBC count 5/mm3 is extremely low and indicates severe anemia. This finding suggests that the treatment may not be having the desired therapeutic effect.
C. Hemoglobin 6.8 g/dL is very low and indicates severe anemia. This is a concerning finding and suggests that the treatment may not be effective.
D. This is the correct answer. A platelet count of 98,000/mm3 is within a range that is generally considered acceptable for a child receiving treatment for leukemia. While it is lower than normal, it is not severely low and suggests that the treatment may be having a therapeutic effect.
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