A nurse is caring for a child who received partial-thickness burns to over 50% of his body 10 days ago and has splints over his joints to prevent contractures. Which of the following actions should the nurse take? (Select all that apply.)
Provide a high-calorie det
Monitor intake and output.
Change dressings using aseptic technique
Remove splints during sleep
Administer analgesics IM
Correct Answer : A,B,C
A. Providing a high-calorie diet is important for a child with extensive burns to support wound healing and recovery.
B. Monitoring intake and output is crucial to assess fluid balance and ensure that the child is receiving enough fluids and nutrients for healing.
C. Changing dressings using an aseptic technique helps prevent infection, which is a significant risk in burn wounds.
D. Removing splints during sleep is not recommended, as they are in place to prevent contractures. They should be worn consistently, including during sleep.
E. Administering analgesics IM (intramuscularly) is not typically indicated. Pain
management can be achieved through various routes, and IM administration may not be necessary. Additionally, it's important to consider the child's pain level and choose the most appropriate and effective route for analgesia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. WBC count 15,000/mm3 is elevated, which may indicate ongoing leukemia activity. It does not necessarily indicate a therapeutic effect.
B. RBC count 5/mm3 is extremely low and indicates severe anemia. This finding suggests that the treatment may not be having the desired therapeutic effect.
C. Hemoglobin 6.8 g/dL is very low and indicates severe anemia. This is a concerning finding and suggests that the treatment may not be effective.
D. This is the correct answer. A platelet count of 98,000/mm3 is within a range that is generally considered acceptable for a child receiving treatment for leukemia. While it is lower than normal, it is not severely low and suggests that the treatment may be having a therapeutic effect.
Correct Answer is B
Explanation
A. Rotavirus vaccine is not typically indicated for adolescents. It is usually administered to infants.
B. Correct. Adolescents with sickle cell anemia are at increased risk for infections,
including those caused by Streptococcus pneumoniae. The pneumococcal conjugate vaccine (PCV) helps protect against certain types of pneumococcal bacteria.
C. The MMR vaccine provides immunity against measles, mumps, and rubella, but it is not specifically indicated for adolescents with sickle cell anemia. They should receive
this vaccine as recommended for their age group.
D. The RSV vaccine is primarily recommended for infants and young children at high risk for severe respiratory syncytial virus (RSV) infection. It is not typically indicated for adolescents with sickle cell anemia.
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