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 A
A. Increased restlessness can indicate hypoxia, pain, or worsening shock, which are critical concerns in a toddler with significant burns. This finding should be reported immediately.
B. Respiratory rate of 25/min is within the normal range for a toddler (22-37 breaths per minute) and does not require immediate intervention.
C. Bowel sounds of 20/min are normal and do not indicate a complication.
D. Urinary output of 35 mL/hr is adequate for a toddler (goal: ≥1-2 mL/kg/hr, which would be ≥20-40 mL/hr for a 20 kg child) and does not require reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Gonorrhea is a nationally notifiable sexually transmitted infection (STI). This means that healthcare providers are required to report cases of gonorrhea to public health authorities to track and monitor the spread of the disease.
B. Bacterial vaginosis and trichomoniasis are common STIs but are not nationally notifiable.
C. Genital herpes simplex virus is a common STI but is not nationally notifiable.
D. Human papillomavirus (HPV) is a common STI, but it is not nationally notifiable.
However, HPV vaccines are recommended to prevent certain strains of the virus that can cause cervical cancer.
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