What is the highest priority nursing diagnosis for a pediatric client with a third-degree circumferential burn of the right arm?
Risk for Altered Tissue Perfusion
Impaired Physical Mobility
Risk for Altered Nutrition: Less than Body Requirements
Risk for Fluid Imbalance
The Correct Answer is A
Choice A reason: A third-degree circumferential burn can compromise blood flow, posing an immediate risk for altered tissue perfusion, which can lead to tissue necrosis and limb loss.
Choice B reason: While impaired physical mobility is a concern, it is not as immediately life-threatening as altered tissue perfusion.
Choice C reason: Nutritional needs are important for healing, but the immediate threat to life from a third-degree burn is the risk for altered tissue perfusion.
Choice D reason: Fluid imbalance is a significant concern due to the potential for burn-induced edema and dehydration; however, the most immediate life-threatening issue is altered tissue perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: An elevated white blood count (WBC) is not typically a side effect of chemotherapy; in fact, chemotherapy often leads to a decreased WBC count.
Choice B reason: This is the correct choice. Bone marrow suppression is a common side effect of chemotherapy, leading to a decreased production of blood cells and necessitating precautions to prevent infection.
Choice C reason: T-cell mediated hypersensitivity is not a common side effect of chemotherapy that would dictate the type of precautions needed.
Choice D reason: Stomatitis is a possible side effect of chemotherapy, but it does not primarily determine the type of precautions required as bone marrow suppression does.
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: Administering oxygen helps increase the oxygen saturation during a 'tet' spell.
Choice B reason: The Trendelenburg position is not recommended for 'tet' spells as it does not help alleviate the hypercyanotic episode.
Choice C reason: While important for overall assessment, drawing blood for serum hemoglobin is not an immediate intervention during a 'tet' spell.
Choice D reason: Placing the infant in a knee-chest position increases systemic vascular resistance, which can help improve oxygenation.
Choice E reason: Administering morphine is appropriate as it helps to relax the infant, reducing the work of breathing and improving oxygenation.
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