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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct instruction. Varicella (chickenpox) is highly contagious. The child should be kept away from others until all lesions are crusted over and no new lesions have formed for at least 24 hours. This typically indicates that the child is no longer contagious.
B. Applying calamine lotion can help alleviate itching and discomfort associated with the vesicles. This is a supportive measure but does not address the contagious nature of the disease.
C. Dressing the child in warm clothing is not specific to the management of varicella. It is important to keep the child comfortable, but this instruction does not address the
contagious period.
D. It is generally safe to give the child a bath during varicella. Warm baths with mild soap can help soothe itching. However, the child should be dried gently to avoid breaking open any vesicles.
Correct Answer is ["2.2"]
Explanation
To calculate the dose of ondansetron for a child who is receiving chemotherapy, the nurse needs to use the following formula:
Dose (mL) = (Dose ordered in mg / Dose available in mg) x Volume available in mL
In this case, the dose ordered in mg is 0.15 mg/kg x 29.4 kg, which equals 4.41 mg. The dose available in mg is 4 mg, and the volume available in mL is 2 mL. Therefore, the dose in mL is:
Dose (mL) = (4.41 mg / 4 mg) x 2 mL Dose (mL) = 2.205 mL
The nurse should round the answer to the nearest tenth, so the final answer is 2.2 mL. The nurse should administer 2.2 mL of ondansetron IV to the child who is receiving chemotherapy.
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