The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is

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Question 1 of 5

The nurse is caring for a 10 year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is

Correct Answer: A

Rationale: Urine output of 0.5-1 ml/kg/hr (30 ml/hr for a 10-year-old) indicates adequate hydration.

Question 2 of 5

When assisting a patient with a cane, which side should the nurse stand on?

Correct Answer: A

Rationale: Standing on the side opposite the patient's weaker leg when assisting with a cane provides optimal support, as the cane is typically held on the stronger side to bear weight, while the nurse stabilizes the weaker side. Standing opposite the stronger leg reduces assistance where it's most needed. Any side ignores biomechanics, risking imbalance. Directly in front obstructs the path and hinders movement. This positioning leverages the cane's role as a weight-bearing aid, ensuring safety and confidence during ambulation, a critical nursing consideration for mobility-impaired patients.

Question 3 of 5

When applying elastic stockings to a patient's legs, what should the nurse ensure?

Correct Answer: C

Rationale: Applying elastic stockings in the morning ensures they're put on before dependent edema worsens from gravity, maximizing their role in promoting venous return and preventing clots. Rolling them down to the ankles negates their purpose full leg coverage is key. Tightness matters, but fit must be correct, not excessive, to avoid constriction. Loose stockings fail to compress adequately, reducing effectiveness. Nurses time this intervention when swelling is minimal, aligning with circulatory needs and enhancing patient comfort and safety throughout the day.

Question 4 of 5

What is the purpose of using a footboard at the foot of the bed for a patient?

Correct Answer: C

Rationale: A footboard maintains proper alignment of the legs and feet by preventing foot drop where toes point downward from prolonged bed rest preserving dorsiflexion and reducing contracture risk. Comfort might improve indirectly, but alignment is the goal. Restricting movement isn't accurate it prevents deformity, not mobility itself. Decoration is irrelevant; it's functional. Nurses position it to support the soles, countering gravity's pull on immobile patients, ensuring long-term musculoskeletal health and aiding future ambulation.

Question 5 of 5

What should a nurse consider when assisting a patient with personal hygiene tasks?

Correct Answer: C

Rationale: Respecting the patient's cultural preferences and privacy ensures dignity and comfort during hygiene tasks, acknowledging beliefs (e.g., modesty) and personal boundaries. Prioritizing nurse convenience neglects patient-centered care, reducing trust. Weekly hygiene risks infection and discomfort daily care is standard. Speeding through sacrifices quality and sensitivity, potentially distressing the patient. Nurses ask about preferences, use privacy measures like curtains, and adapt techniques, balancing hygiene needs with respect, a key aspect of culturally competent, compassionate care.

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