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 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.

A. Hypertension B. Increased urine output C. Increased respiratory rate D. Capillary refill of 2 seconds

Correct Answer is C

Explanation

A. Hypertension is not a typical finding in severe dehydration. In fact, dehydration often leads to decreased blood pressure.

B. Increased urine output is not a typical finding in severe dehydration. Dehydration leads to decreased urine output as the body tries to conserve fluids.

C. This is the correct answer. In severe dehydration, the body compensates by increasing the respiratory rate to try to maintain oxygen levels and remove excess carbon dioxide. This is a compensatory mechanism in response to metabolic acidosis, which can occur with dehydration.

D. A capillary refill of 2 seconds indicates normal perfusion. In severe dehydration, capillary refill may be prolonged, indicating poor perfusion.

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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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