A nurse is caring for an 8-year-old child on an inpatient pediatric unit.
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Body System |
Findings |
|
Integumentary |
Skin feels cool to the touch. Capillary refill 3 seconds in left foot Dressing on left hand shows small amount of moisture through gauze. |
|
Vital Signs |
Blood pressure 102/50 mm Hg Temperature 35.8° C (96.4° F) Respiratory rate 20/min |
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Genitourinary |
Output of 25 mL dark amber urine through catheter |
Skin feels cool to the touch.
Capillary refill 3 seconds in left foot
Dressing on left hand shows small amount of moisture through gauze.
Blood pressure 102/50 mm Hg
Temperature 35.8° C (96.4° F)
Respiratory rate 20/min
Output of 25 mL dark amber urine through catheter
The Correct Answer is ["A","B","D","E","G"]
Rationale for correct choices:
- Skin feels cool to the touch: Cool skin indicates poor peripheral perfusion, which can signal early hypovolemic shock in a child with burns. Prompt assessment and interventions, such as fluid resuscitation, are necessary.
- Capillary refill 3 seconds in left foot: Delayed capillary refill reflects compromised circulation and decreased tissue perfusion. Early recognition and intervention help prevent progression to shock.
- Blood pressure 102/50 mm Hg: Mild hypotension combined with tachycardia, cool skin, and delayed capillary refill suggests early hypovolemic shock, a life-threatening complication requiring immediate attention.
- Temperature 35.8° C (96.4° F): Hypothermia can occur due to heat loss from burn injuries, increasing the risk for coagulopathy, impaired wound healing, and further hemodynamic instability.
- Output of 25 mL dark amber urine through catheter: Low and concentrated urine output indicates possible dehydration or reduced renal perfusion, which can progress to acute kidney injury if not addressed urgently.
Rationale for incorrect choices:
- Respiratory rate 20/min: Although slightly decreased from admission, this is within a near-normal range for an 8-year-old and not immediately concerning. Continuous monitoring is appropriate, but it is not an urgent priority compared with perfusion and hemodynamic indicators.
- Dressing on left hand shows small amount of moisture through gauze: Minor moisture in the dressing may reflect mild wound exudate, which requires routine monitoring and dressing changes. It does not indicate an immediate life-threatening risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Wear a gown while providing personal hygiene: Contact precautions are required for clients with Clostridium difficile to prevent transmission via contaminated surfaces or direct contact. Wearing a gown during personal care protects the nurse’s clothing and skin from spores.
B. Place the client in a room with negative airflow: Negative airflow rooms are required for airborne infections such as tuberculosis or measles. C. difficile is spread via the fecal–oral route and does not require airborne isolation measures.
C. Apply a mask when providing care: Masks are necessary for droplet or airborne pathogens, but C. difficile spores are transmitted through direct or indirect contact, not respiratory droplets, so masks are not routinely required unless there is another indication.
D. Wipe the stethoscope with alcohol after leaving the client's room: C. difficile spores are resistant to alcohol-based disinfectants. Cleaning equipment requires soap and water or a sporicidal disinfectant to effectively remove spores and prevent spread.
Correct Answer is D
Explanation
Rationale:
A. Provide a tracheostomy tray at the bedside: A tracheostomy tray is not routinely required for seizure precautions, as airway obstruction in seizures is usually managed through positioning and suctioning.
B. Place the client in supine position: The supine position can increase the risk of airway obstruction and aspiration after a seizure. A side-lying position is preferred to help maintain an open airway and promote drainage of secretions.
C. Place a plastic tongue depressor at the client's bedside: Placing any object in a client’s mouth during or after a seizure can cause injury to the teeth, gums, or airway. Modern seizure precautions avoid using tongue blades or depressors entirely.
D. Insert an IV saline lock: Having IV access readily available allows rapid administration of emergency medications such as benzodiazepines if the client experiences another seizure. This intervention supports prompt treatment and stabilization.
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