A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

Remove clothing.

Administer pain medication.

Assess respiratory status.

Insert a Foley catheter.

Answer and Explanation

The Correct Answer is C

A. Remove clothing. Removing clothing is important to prevent further injury from retained heat or chemicals, but it is not the first priority compared to ensuring a patent airway and adequate breathing.
B. Administer pain medication. Pain management is important but comes after ensuring the child's airway and respiratory status are stable.
C. Assess respiratory status. Burns on the face and chest can compromise the airway and breathing. Assessing respiratory status is the first priority to ensure the child’s airway is not obstructed and that they are receiving adequate oxygen.
D. Insert a Foley catheter. Inserting a Foley catheter may be necessary to monitor urine output and assess kidney function in severe burns, but it is not the first priority compared to assessing respiratory status.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Pain: Although pain management is important for comfort and to improve quality of life, in this scenario, the child’s pain is rated as a 3 on the FLACC scale, which is moderate. Immediate pain does not seem to be the primary or most urgent concern compared to the high fever and potential underlying conditions.
Bruising: The presence of bruising in various stages of healing and petechiae suggests a possible underlying hematologic issue or trauma. While concerning and needing further investigation, it does not require immediate intervention compared to the fever.
Heart rate: The heart rate is elevated at 150 beats per minute, which could be a response to the fever, pain, or anxiety. Addressing the fever may help in normalizing the heart rate.

Respiratory rate: The respiratory rate is elevated but not critically so (normal for a toddler is 20-30 breaths per minute). There is no increased work of breathing noted, so while monitoring is important, it is not the most immediate priority compared to the fever and lab abnormalities.

Nasal stuffiness: While nasal congestion can be uncomfortable and contribute to respiratory distress, it is not an immediate threat to the child’s health and can be managed after addressing the fever and the concerning laboratory values.

Petechiae: Petechiae are small red or purple spots that can indicate bleeding under the skin and may be associated with a bleeding disorder or infection. However, the underlying cause might be revealed through laboratory investigations, which are prioritized after managing the fever. Immediate intervention for petechiae alone is not usually required unless there is evidence of significant bleeding or other acute symptoms.

A. Diarrhea B. Swollen joints C. Abdominal mass D. Jaundice

Correct Answer is C

Explanation

A. Diarrhea: Diarrhea is not a typical finding associated with Wilms' tumor.
B. Swollen joints: Swollen joints are not associated with Wilms' tumor and would suggest a different condition.
C. Abdominal mass: Wilms' tumor typically presents with an asymptomatic abdominal mass that may be firm, non-tender, and palpable.
D. Jaundice: Jaundice is not typically associated with Wilms' tumor and would suggest liver dysfunction or another underlying cause.

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A child is brought to the emergency department with burns on the face and chest. What is the nurse's first priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a toddler. Exhibits A nurse is assisting in the care of a client. Complete the following sentence by using the list of options. The nurse should first address the child's dropdown followed by the child's dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A nurse is collecting data from a 1-year-old child who has Wilms' tumor. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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