A nurse is caring for a school-age child who has full-thickness burns to 30% of the total body surface area (TBSA). The nurse is initiating the client's plan of care. Complete the following sentence by using the list of options.
The client is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Choice A reason: Hypovolemia is a condition of low blood volume due to fluid loss from the burn injury. It can cause decreased urine output, hypotension, tachycardia, and poor skin turgor. The nurse should monitor the client's vital signs, fluid intake and output, and weight. The nurse should administer lactated Ringer's solution to maintain urine output of 30 ml/hr.
Choice B reason: Hyperkalemia is a condition of high potassium levels in the blood due to cellular damage from the burn injury. It can cause peaked T waves, dysrhythmias, muscle weakness, and cardiac arrest. The nurse should monitor the client's serum potassium levels, electrocardiogram, and cardiac status. The nurse should avoid administering potassium-containing fluids or medications.
Choice C reason: Hypocalcemia is a condition of low calcium levels in the blood due to fluid shifts from the burn injury. It can cause positive Chvostek's sign, tetany, seizures, and hypotension. The nurse should monitor the client's serum calcium levels, neurological status, and blood pressure. The nurse should administer calcium supplements as prescribed.
Choice D reason: Hypernatremia is a condition of high sodium levels in the blood due to fluid loss from the burn injury. It can cause dry mucous membranes, thirst, agitation, and seizures. The nurse should monitor the client's serum sodium levels, hydration status, and mental status. The nurse should administer hypotonic fluids as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The posterior fontanel, which is the soft spot at the back of the infant's head, normally closes by 2 to 4 months of age. Therefore, the nurse should expect to find a closed posterior fontanel in a 6-month-old infant.
Choice B reason: Lateral incisors, which are the teeth on either side of the central incisors, normally erupt between 7 and 10 months of age. Therefore, the nurse should not expect to find lateral incisors in a 6-month-old infant.
Choice C reason: Sitting steadily without support is a developmental milestone that is usually achieved between 6 and 9 months of age. Therefore, the nurse may or may not expect to find this skill in a 6-month-old infant, depending on the individual variation.
Choice D reason: Using thumb and index fingers in a pincer grasp is a fine motor skill that is usually developed between 9 and 12 months of age. Therefore, the nurse should not expect to find this skill in a 6-month-old infant.
Correct Answer is A
Explanation
Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.
Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.
Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.
Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.
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