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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Urinary tract infection: Dysuria (painful urination) and urgency are common symptoms of urinary tract infection (UTI) in children.
B. Nephrotic syndrome: Nephrotic syndrome typically presents with proteinuria, edema, and hypoalbuminemia, not dysuria and urgency.
C. Acute glomerulonephritis: Acute glomerulonephritis may present with hematuria, proteinuria, hypertension, and edema, but not typically with dysuria and urgency.
D. Vesicoureteral reflux: Vesicoureteral reflux may present with recurrent UTIs but is not typically associated with dysuria and urgency as primary symptoms.
Correct Answer is ["A","B","E"]
Explanation
A. Empty bladder completely with each void: Ensuring the bladder is completely emptied helps to reduce the risk of residual urine, which can promote bacterial growth and increase the risk of UTIs.
B. Avoid bubble baths: Bubble baths can irritate the urethra and promote bacterial growth, increasing the risk of UTIs. Avoiding them helps in prevention.
C. Increase fiber intake: Increasing fiber intake is not directly related to UTI prevention and is more relevant to digestive health.
D. Wear nylon underpants; Nylon underpants can trap moisture and create a warm environment that supports bacterial growth. Cotton underwear is recommended instead.
E. Watch for manifestations of infection: Being vigilant for signs of infection such as fever, pain, or changes in urination patterns is crucial for early detection and treatment of UTIs.
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