A nurse is caring for a child who received partial -thickness burn s to over 50% of his body 10 days ago and has splints over his joints to prevent contractures.
Which of the following action should the nurse take? (select all that apply.).
provide a high-calories diet
Administer analgesics IM.
monitor intake and output
remove splints during sleep.
change dressing using aseptic technique.
Correct Answer : A,C,E
Choice A rationale
Providing a high-calorie diet is a recommended action for a child who has received partial-thickness burns to
over 50% of his body. After a burn injury, the body needs extra calories and protein to heal, fight infection, and maintain its functions. A high-calorie diet can help meet these increased nutritional needs.
Choice B rationale
Administering analgesics intramuscularly (IM) is not a recommended action for a child with partial- thickness burns. Pain management is crucial in burn care, but analgesics should be given orally or intravenously, not IM, to avoid additional pain and tissue damage.
Choice C rationale
Monitoring intake and output is a recommended action for a child who has received partial-thickness burns to over 50% of his body. This can help assess the child’s hydration status, kidney function, and response to fluid replacement therapy.
Choice D rationale
Removing splints during sleep is not a recommended action for a child with partial-thickness burns. Splints are used to prevent contractures by keeping the joints in a functional position. They should be worn as prescribed by the healthcare provider, which often includes during sleep.
Choice E rationale
Changing dressings using aseptic technique is a recommended action for a child who has received partial- thickness burns to over 50% of his body. This can help prevent infection, promote healing, and assess the burn’s progress.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Meperidine is not the first choice for pain management in sickle cell crisis due to its potential to cause seizures and other side effects.
Choice B rationale
Bed rest is recommended during a sickle cell crisis to decrease the body’s demand for oxygen, reduce the workload of the heart, and improve blood flow.
Choice C rationale
Limiting fluid intake is not recommended during a sickle cell crisis. Adequate hydration is important to prevent further sickling of cells and to maintain kidney function.
Choice D rationale
Cold compresses can cause vasoconstriction and may exacerbate the crisis. Warm compresses are usually recommended to increase blood flow and reduce pain.
Correct Answer is C
Explanation
Choice A rationale
Children with autism spectrum disorder often thrive on routines and predictability. Varying daily routines can be distressing and may lead to increased anxiety.
Choice B rationale
Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.
Choice C rationale
This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.
Choice D rationale
Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.
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