A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full-thickness burn to 10% of his body. Which of the following findings should the nurse report to the provider?
Increased restlessness
Respiratory rate 25/min
Bowel sounds 20/min
Urinary output 35 mL/hr
The Correct Answer is D
A. Increased restlessness can be a normal response to pain and discomfort in a toddler
with a burn injury. It is important to address pain management, but this finding alone may not require immediate reporting to the provider.
B. A respiratory rate of 25 breaths per minute is within the normal range for a toddler. It does not require immediate reporting to the provider.
C. Bowel sounds of 20 per minute are within the normal range for a toddler. It does not require immediate reporting to the provider.
D. A urinary output of 35 mL/hr is lower than the expected urine output for a toddler. In a child of this weight, the expected urine output is typically higher. This finding may
indicate decreased renal perfusion, which should be reported to the provider for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct action. Offering a pacifier coated with an oral sucrose solution before the injections can provide comfort and help alleviate pain associated with the immunizations.
B. Administering immunizations into the deltoid muscle is not recommended for infants.
For young infants, immunizations are typically given in the anterolateral thigh muscle.
C. Using a 20-gauge needle is not recommended for infants, as it is a larger gauge and may cause more discomfort. A smaller gauge needle is typically used for infant
immunizations.
D. Applying an eutectic mixture of local anesthetics (EMLA) cream immediately before the injections is not a standard practice for routine infant immunizations. It may not be necessary for most infants and could increase the overall time and complexity of the procedure.
Correct Answer is B
Explanation
A. A preschool-age child is not expected to give a logical explanation for death. They may not fully understand the concept of death in the same way an older child or adult does.
B. Correct. It is common for preschool-age children to be curious about what happens to the body after death. This curiosity is an age-appropriate response to death.
C. A preschool-age child may not fully grasp the concept of death as permanent. They may have limited understanding of the irreversibility of death.
D. Feeling responsible for a sibling's death would be an inappropriate and potentially concerning response for a preschool-age child. It may indicate a need for further assessment and support.
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