What is the best initial action for the nurse to take?

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Burns Pediatric Primary Care 7th Edition Test Bank Questions

Question 1 of 5

What is the best initial action for the nurse to take?

Correct Answer: A

Rationale: The best initial action for the nurse to take when a client is experiencing hyperventilation is to try to have the client breathe slower. This is because hyperventilation is often caused by rapid, shallow breathing and slowing down the breathing pattern can help restore normal gas exchange and alleviate symptoms. Providing oxygen via a nasal cannula or administering sodium bicarbonate would not directly address the underlying issue of hyperventilation. Monitoring fluid balance is important for overall assessment but not the priority when dealing with acute respiratory distress due to hyperventilation.

Question 2 of 5

The nurse is conducting an assessment on a school-age child with urosepsis. Which assessment finding should the nurse expect?

Correct Answer: A

Rationale: In a school-age child with urosepsis, the nurse should expect the assessment finding of fever with a positive blood culture. Urosepsis is a severe infection in the urinary tract that has spread to the bloodstream, causing systemic symptoms such as fever. Positive blood cultures indicate the presence of bacteria in the bloodstream, confirming the diagnosis of sepsis. Other common symptoms of urosepsis may include chills, rapid heart rate, increased respiratory rate, and altered mental status. Proteinuria and edema (choice B) are more indicative of kidney disorders such as nephrotic syndrome rather than urosepsis. Oliguria and hypertension (choice C) may be seen in conditions like acute kidney injury but are not specific to urosepsis. Anemia and thrombocytopenia (choice D) are more characteristic of conditions such as hemolytic uremic syndrome rather than urosepsis.

Question 3 of 5

The LEAST helpful advice for a 10-month-old baby refusing spoon feeding is

Correct Answer: B

Rationale: Offering softer diet may not address refusal due to developmental factors.

Question 4 of 5

What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?

Correct Answer: C

Rationale: The correct size of a suction catheter is usually determined by the patient's weight, rather than height. For James, who weighs approximately 145 lbs, a Fr. 10 suction catheter would be suitable. Suction catheter sizes typically range from Fr. 5 (smaller) to Fr. 18 (larger), with Fr. 10 being a common size for an adult patient of James' weight. Using a catheter that is too small may not effectively clear secretions, while one that is too big may cause discomfort or damage to the airways.

Question 5 of 5

Which white blood cells are involved in releasing histamine during an allergic reaction?

Correct Answer: A

Rationale: Basophils are a type of white blood cell that are involved in releasing histamine during an allergic reaction. When an allergen triggers the immune system, basophils release histamine and other chemical mediators. Histamine plays a key role in the inflammatory response associated with allergies, leading to symptoms such as itching, hives, and swelling. Basophils are known for their role in allergic reactions and are an important part of the body's defense against parasites and in the inflammatory response.

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