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 D

Explanation

A. Percussing ankle and knee reflexes. Safe and non-invasive, and does not risk disturbing the tumor.
B. Assessing for bowel sounds. Routine part of assessment and does not involve manipulating the tumor.
C. Performing range-of-motion exercises on lower extremities. Safe and non-invasive, unrelated to the abdominal tumor.
D. Palpating the abdomen. Palpating the abdomen in a child with Wilms' tumor is avoided to prevent the risk of tumor rupture and subsequent metastasis.

A. "Give your infant an oral rehydration solution." B. "You might want to try switching to a different formula." C. "Bring your infant into the clinic today to be seen." D. "Burp your child more frequently during feedings."

Correct Answer is C

Explanation

A. "Give your infant an oral rehydration solution." While rehydration is important, projectile vomiting could indicate a more serious underlying issue that needs medical evaluation.
B. "You might want to try switching to a different formula." Formula intolerance is less likely to cause projectile vomiting. A change in formula should not be suggested without ruling out more serious conditions first.
C. "Bring your infant into the clinic today to be seen." Projectile vomiting in an infant, especially when followed by hunger, can indicate pyloric stenosis, a condition that requires prompt medical evaluation. The infant should be seen by a healthcare provider to determine the cause and initiate appropriate treatment.
D. "Burp your child more frequently during feedings." Burping can help with regular gas and minor feeding issues, but it is unlikely to resolve projectile vomiting.

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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

Which physical assessment technique will the nurse omit when caring for a 2-year-old child diagnosed with Wilms' tumor?

Correct Answer is D

Explanation

A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

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