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

A.

Respiratory Rate

B.

Bowel Sounds

C.

Burns of the mouth

D.

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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Related Questions

Correct Answer is C

Explanation

A. Is a congenital condition where the layers of the intestinal wall do not form properly. – Incorrect. This describes congenital gastrointestinal disorders like duodenal atresia, not intussusception.

B. Results from the twisting of the intestine, causing a blockage in the passage of food. – Incorrect. This describes volvulus, which is different from intussusception.

C. Occurs when one segment of the intestine slides into another, which can cut off blood supply. – Correct. Intussusception is a telescoping of the intestine, leading to obstruction and ischemia.

D. Is a consequence of weakened abdominal muscles, allowing a portion of the intestine to bulge. – Incorrect. This describes a hernia, not intussusception.

Correct Answer is C

Explanation

A. Resume playing on their soccer team next year. – Incorrect. Contact sports pose a risk of injury to the remaining kidney and should be avoided.

B. Only participate in nonphysical activities from now on. – Incorrect. While high-impact sports should be avoided, moderate noncontact physical activity is encouraged for overall health.

C. Participate in noncontact sports like swimming as they grow. – Correct. Noncontact sports like swimming, running, or cycling are safe options.

D. Engage in any sports once the incision heals. – Incorrect. Some sports pose a risk of kidney injury and should be avoided.

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