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 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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dark brown blood noted in emesis is a concerning finding and may indicate active bleeding. This requires immediate intervention by the nurse, as post-tonsillectomy hemorrhage is a potential complication.
B. An axillary temperature of 38° C (100° F) is slightly elevated, but it is not the most concerning finding in this situation. It may be expected after surgery due to inflammation and the body's stress response.
C. A pain level of 5 on the FACES scale indicates moderate pain. While pain management is important, it is not the most urgent concern in this situation.
D. Frequent swallowing may be expected after a tonsillectomy due to postoperative
throat discomfort. It is important to monitor for bleeding, but dark brown blood in emesis is a more immediate concern.
Correct Answer is A
Explanation
A. This statement indicates understanding. Giving water after administering digoxin helps ensure that the medication is swallowed and reaches the stomach, which is important for proper absorption.
B. Giving digoxin with foods high in fiber is not a specific instruction for administering this medication. It is important to follow the healthcare provider's specific dosing
instructions.
C. If a child vomits after taking digoxin, the parent should not give another dose. They should wait until the next scheduled dose. Double dosing can lead to overdose.
D. Mixing digoxin with juice is not recommended, as it may affect the absorption of the medication. It is best to give digoxin with a small amount of water.
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