The nurse is caring for a 2-month-old child who suffered burns on his face due to abuse. What is the nurse’s immediate priority concern when caring for this patient?

Managing the airway.

Monitoring renal function.

Restoring fluid volume.

Assessing for shock.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The immediate priority when caring for a patient with facial burns, especially a 2-month-old child, is managing the airway. Burns can cause swelling and compromise the airway, leading to respiratory distress. Therefore, ensuring a patent airway is crucial in these cases.

Choice B rationale

While monitoring renal function is important in burn patients due to the risk of acute kidney injury from decreased perfusion, it is not the immediate priority.

Choice C rationale

Restoring fluid volume is a critical part of burn management. However, it is not the immediate concern when the airway could be compromised.

Choice D rationale

Assessing for shock is important in burn patients due to the risk of hypovolemic shock from fluid loss. However, airway management takes precedence.

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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

While maintaining a cool, dry environment can be comfortable for the child, it is not specifically related to tracheostomy care. Humidity can actually be beneficial for a child with a tracheostomy, as it helps to keep the airway moist and prevent mucus from becoming too thick.

Choice B rationale

Having emergency tracheostomy equipment available at all times is crucial. This should include a spare tracheostomy tube of the same size and one size smaller, suction equipment, and a bag-valve-mask device. In case of a problem with the tracheostomy tube (such as blockage or accidental dislodgement), it is important to have the necessary equipment immediately available.

Choice C rationale

Changing the tracheostomy tube at the ordered frequency is important to prevent blockage and infection. The frequency will depend on various factors, including the type of tracheostomy tube and the child’s specific condition.

Choice D rationale

Monitoring the thickness and color of secretions can help to detect infections or other complications. Changes in secretions can be an early sign of problems such as tracheitis or pneumonia.

A. Distract him until he gets involved in another activity, then take the blanket for washing. B. Acknowledge that it seems to be his favorite blanket and allow him to keep it with him. C. Tell him that you want to take it home to wash and that you will bring it back. D. Suggest getting him another blanket so that he will not mind giving that one up. .

Correct Answer is B

Explanation

Choice A rationale

Distracting the patient and then taking the blanket for washing might seem like a practical solution, but it can lead to trust issues. The patient may feel betrayed or tricked, which can negatively affect the therapeutic relationship between the nurse and the patient.

Choice B rationale

Acknowledging that the blanket seems to be his favorite and allowing him to keep it with him is the best course of action. The blanket likely provides comfort and security to the patient.

Taking it away, even temporarily, can cause distress. The nurse should respect the patient’s attachment to the blanket and look for alternative solutions for maintaining hygiene, such as offering to clean the blanket when the patient is ready to part with it temporarily.

Choice C rationale

Telling the patient that you want to take the blanket home to wash and that you will bring it back might not be reassuring enough for the patient. The patient may worry about the blanket getting lost or not returned, which can cause unnecessary anxiety.

Choice D rationale

Suggesting getting him another blanket so that he will not mind giving up the current one might not work. The patient’s attachment is likely to the specific blanket, not to blankets in general. A new blanket will not have the same familiarity and comforting effect as the old one.

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The nurse is caring for a 2-month-old child who suffered burns on his face due to abuse. What is the nurse’s immediate priority concern when caring for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When teaching home tracheotomy care to caregivers of a child with a tracheostomy tube, which of the following topics are essential to include in teaching? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A patient arrives at the hospital with a stained, ragged baby blanket.When his mother tries to remove the blanket to take it home for washing, he hides under the bed and clings to the blanket.What is the best course of action for the nurse?

Correct Answer is B

Explanation

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