A nurse is creating a plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include in the plan?

Maintain aseptic technique during the child's dressing changes.

Provide low-calorie snacks for the child several times each day.

Apply continuous passive motion devices to the child's lower extremities during periods of rest.

Administer pain medication to the child 30 min following physical therapy.

Answer and Explanation

The Correct Answer is A

A. "Maintain aseptic technique during the child's dressing changes." Aseptic technique reduces the risk of infection, which is critical for children with burns as their immune response may be compromised.
B. "Provide low-calorie snacks for the child several times each day." Children with burns require a high-calorie, high-protein diet to promote healing and compensate for increased metabolic demands.
C. "Apply continuous passive motion devices to the child's lower extremities during periods of rest." Passive motion devices are not typically indicated for burn injuries unless there is joint involvement requiring physical therapy for mobility restoration.
D. "Administer pain medication to the child 30 min following physical therapy." Pain medication should be administered before physical therapy to improve tolerance and participation.

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Correct Answer is B

Explanation

A. Urine output of 50 mL in 2 hr: This is within normal limits for a child and does not indicate an immediate concern.
B. Lethargy: Lethargy is a potential sign of increased intracranial pressure (ICP), which is a critical complication of VP shunt placement and requires immediate intervention.
C. Respiratory rate 24/min: This is within the normal range for a 4-year-old child.
D. Absent Babinski reflex: This is a normal finding in children over 2 years old, as the reflex typically disappears by that age.

A. "I will give lansoprazole 30 minutes after their feeding." B. "I will lay my baby on her side after feedings." C. "I will add rice cereal to my baby's feedings." D. "I will use a nipple that has a wide base to feed them."

Correct Answer is C

Explanation

A. "I will give lansoprazole 30 minutes after their feeding." Lansoprazole should be administered 30 minutes before feedings to effectively reduce stomach acid.
B. "I will lay my baby on her side after feedings." Side-lying positioning increases the risk of sudden infant death syndrome (SIDS). The infant should be placed on their back.
C. "I will add rice cereal to my baby's feedings." Adding rice cereal can thicken the formula, helping to reduce reflux episodes.
D. "I will use a nipple that has a wide base to feed them." While wide-based nipples can be helpful for latch during breastfeeding, they do not significantly impact GER management.

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A nurse is creating a plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include in the plan?

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