Nokea
During early postburn care of the child, it is essential for the nurse to closely monitor which of the following?
- A. Unburned skin
- B. Bowel elimination
- C. I.V. fluid therapy
- D. Pupillary response to light
Correct Answer: C
Rationale: I.V. fluid therapy is critical in the early postburn phase to prevent hypovolemic shock and maintain organ perfusion. Close monitoring ensures adequate resuscitation and prevents complications like over- or under-hydration.
You may also like to solve these questions
Which response by the nurse best explains why insulin must be given subcutaneously?
- A. The oral form of insulin can lead to the worsening of diabetes.
- B. The oral form of insulin is not yet available for use.
- C. Insulin is a protein that is destroyed by digestive enzymes.
- D. Insulin given by the oral route causes severe vomiting.
Correct Answer: C
Rationale: Insulin is a protein hormone that would be broken down by digestive enzymes in the gastrointestinal tract if taken orally, rendering it ineffective. Subcutaneous administration ensures it reaches the bloodstream intact.
The most common side effect of tocolytic agents is:
- A. Vaginal bleeding.
- B. Abdominal pain.
- C. Nausea,vomiting.
- D. Palpitations.
- E. Oliguria.
Correct Answer: D
Rationale: Tocolytics such as beta-agonists commonly cause palpitations due to their sympathomimetic effects. Other side effects are less frequent or not primarily associated.
The nurse correctly advises the parents to avoid administering medications containing which ingredient to their child who has hemophilia?
- A. Acetaminophen
- B. Aspirin
- C. Ibuprofen
- D. Penicillin
Correct Answer: B
Rationale: Aspirin inhibits platelet function and increases bleeding risk, which is dangerous for a child with hemophilia, a condition characterized by impaired clotting.
Which nursing actions are most appropriate to include in the care plan of a child with nephrotic syndrome? Select all that apply.
- A. Restricting the intake of protein
- B. Weighing the child daily
- C. Completing range-of-motion exercises
- D. Measuring abdominal circumference
- E. Collecting a 24-hour urine specimen
- F. Monitoring blood urea nitrogen (BUN) and creatinine levels
Correct Answer: B,C,D,E,F
Rationale: Daily weighing monitors fluid status, range-of-motion exercises prevent immobility complications, measuring abdominal circumference tracks ascites, collecting urine assesses proteinuria, and monitoring BUN/creatinine evaluates kidney function. Protein restriction is not typical.
If the nurse collects the following data, which assessment finding best indicates the presence of increased intracranial pressure?
- A. Rapid bilateral pupillary response to light
- B. Tympanic temperature of 97.9°F (36.6°C)
- C. Blood pressure of 150/90 mm Hg
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Elevated blood pressure (e.g., 150/90 mm Hg) is a sign of increased intracranial pressure, often part of Cushing's triad (hypertension, bradycardia, irregular respirations), indicating brain compression.