Nokea
What is the nurse aware is the minimum adequate hourly urine output?
- A. 5 mL/hr
- B. 10 mL/hr
- C. 15 mL/hr
- D. 20 mL/hr
Correct Answer: D
Rationale: For children over 2 years, a minimum urine output of 20-30 mL/hr indicates adequate renal perfusion in burn patients.
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The nurse assesses the total body surface area (TBSA) percentage burn as __%.
Correct Answer: 26
Rationale: For a 5-year-old, the TBSA burn is calculated as 26% based on the Burn Size Estimation Table (upper/lower arm 5.5%, hand 2.5%, anterior trunk 13%, genital area 1%, half thigh 4%).
What would help the child with a serious burn meet nutritional needs during the subacute phase of recovery?
- A. Decrease calories because the child will be on bed rest and will not need as many.
- B. Increase calories and protein to compensate for the healing process.
- C. Increase fat to replace the layer of fat next to the burned skin.
- D. Decrease carbohydrates and starches because the pancreas is strained by the healing process.
Correct Answer: B
Rationale: Increased calories and protein are essential to support the high metabolic demands of burn healing.
What is the nurse's first priority?
- A. Assess respiratory status.
- B. Administer pain medication.
- C. Remove clothing.
- D. Insert a Foley catheter.
Correct Answer: A
Rationale: Assessing respiratory status is the priority for facial and chest burns to ensure airway patency.
What does the nurse explain as the most likely cause of this rash?
- A. Sun exposure
- B. Allergic reaction
- C. Infection
- D. Heat and moisture
Correct Answer: D
Rationale: Miliaria (prickly heat rash) is caused by excess heat and moisture, leading to pinhead-sized red papules.
Which allergy would contraindicate the use of silver sulfadiazine (Silvadene) as a topical agent for burns?
- A. Penicillin
- B. Iodine
- C. Tetanus immunizations
- D. Sulfa
Correct Answer: D
Rationale: Silver sulfadiazine is contraindicated in patients with sulfa allergies due to potential adverse reactions.