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 D
Explanation
A. Offer chicken broth: Chicken broth alone may not provide adequate electrolyte replacement and hydration needed for managing diarrhea-related dehydration.
B. Keep NPO until the diarrhea subsides: NPO status is generally not necessary unless the child is unable to tolerate oral fluids. ORT is preferred to maintain hydration.
C. Start hypertonic IV solution: Hypertonic IV solutions are not typically used for routine management of dehydration from diarrhea in children. ORT is safer and effective.
D. Assist with initiating oral rehydration therapy: Oral rehydration therapy (ORT) is the primary intervention for managing dehydration due to diarrhea in children. It helps replace lost fluids and electrolytes and is the recommended first-line treatment.
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