A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

Respiratory Rate

Bowel Sounds

Burns of the mouth

Visual Acuity

Answer and Explanation

The Correct Answer is A

A. Respiratory Rate – Correct. Hydrocarbon poisoning (such as kerosene ingestion) primarily affects the lungs and can lead to aspiration pneumonia, respiratory distress, and chemical pneumonitis.

B. Bowel Sounds – Incorrect. While gastrointestinal effects may occur, they are not the primary concern.

C. Burns of the mouth – Incorrect. Kerosene does not typically cause burns like caustic substances such as acids or alkalis.

D. Visual Acuity – Incorrect. Kerosene does not directly affect vision.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}

Explanation

Hypoxia (Low Oxygen Levels): The child's oxygen saturation has decreased from 95% to 93% on room air, which indicates a decline in oxygenation. Although this level is still within an acceptable range, a further drop could indicate respiratory compromise, especially with signs of labored breathing and a nonproductive cough.

Rationale for incorrect options:

Hypotension: The child's blood pressure remains stable (110/64 mm Hg), ruling out a significant risk of hypotension.

Constipation: While the child has hypoactive bowel sounds and hasn't had a bowel movement in two days, this does not pose the most immediate risk.

Dehydration: The child voided 200 mL of clear, yellow urine, suggesting adequate hydration status.

A. Amblyopia B. Hypotropia C. Otorrhea D. Exotropia

Correct Answer is A

Explanation

A. Amblyopia – Correct. Strabismus can lead to amblyopia (lazy eye) if left untreated.

B. Hypotropia – Incorrect. Hypotropia is a type of strabismus, not a complication.

C. Otorrhea – Incorrect. Otorrhea (ear drainage) is unrelated to strabismus.

D. Exotropia – Incorrect. Exotropia is another form of strabismus rather than a complication.

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A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who was involved in a motor vehicle crash. Exhibits Complete the following sentence by using the list of options. The child is at highest risk for developing dropdown evidenced by the client’s dropdown.

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