RN Pediatric Nursing Online Practice B-with 100% verified solutions-personalized success, Exams of Nursing

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1. A nurse is preparing to administer an immu- nization to a 4 - year-old child. Which of the fol- lowing actions should the nurse plan to take? A. Place the child in a prone position for the immunization. B. Request that the child's caregiver leave the room during the im- munization. C. Administer the im- munization using a 24 - gauge needle. D. Inject the immuniza- tion slowly after aspi- rating for 3 seconds.
2. A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the follow- ing actions should the nurse take during the immediate postictal pe- riod? A. Place the child in a side-lying position. B. Delay documenta- tion until the child is C. Administer the immunization using a 24 - gauge needle. Rationale: The nurse should administer an immu- nization for a 4 - year-old child using a 22 to 25 - gauge needle to minimize the amount of pain the child experiences. A. Place the child in a side-lying position. Rationale: The nurse should place the child in a side-lying position to prevent aspiration.

personalized success fully alert. C. Give the child a high-carbohydrate snack. D. Administer an oral sedative to the child.

3. NGN* A nurse on a pe- diatric unit is admit- ting a preschooler. Af- ter reviewing the in- formation in the med- ical record the nurse should identify that the child is at risk for de- veloping which of the following conditions? Dropdown 1: Splenomegaly Acute post-streptococ- cal glomerulonephritis (APSGN) Dysrhythmias Dropdown 2: Positive mononucleo- sis rapid test Urinary output Cardiovascular as- sessment
4. A nurse is assessing an infant who has a ventricular septal de- fect. Which of the fol- lowing findings should 1. Splenomegaly Rationale: The child's positive mononucleosis rapid test result indicates the presence of infectious mono, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mono. 2. Positive mono rapid test Rationale: The child's positive mononucleosis rapid test result indicates the presence of infectious mono, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mono. A. Loud, harsh murmur Rationale: The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to

personalized success the nurse expect? A. Loud, harsh murmur B. Dysrhythmias C. Weak femoral pulses D. High blood pressure

5. A nurse is providing discharge teaching the guardians of a toddler with a lower leg cast applied 24 hours ago. The nurse should in- struct the guardians to report which of the fol- lowing findings to the provider? A. Capillary refill time < 2 seconds. B. Restricted ability to move the toes. C. Swelling of the cast- ed foot when the leg is dependent. D. Pedal pulse +3 bilat- eral.
6. A nurse is planning an educational program to teach caregivers about protecting their chil- dren from sunburns. the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle. B. Restricted ability to move the toes. Rationale: The nurse should inform the guardians that the restricted ability of the toddler to move their toes is an indication of neuromuscular compromise and requires immediate notification to the provider. Permanent muscle and tissue damage can occur in just a few hours. B. "Choose a waterproof sunscreen with a minimum SPF of 15." Rationale: The nurse should instruct caregivers to apply a waterproof sunscreen with a minimum SPF

personalized success Which of the following instructions should the nurse plan to include? A. "Allow your child to play outside during the hours between 10: am and 2:00 pm." B. "Choose a water- proof sunscreen with a minimum SPF of 15." C. "Dress your child in loose weave polyester fabric prior to sun ex- posure." D. "Reapply sunscreen every 4 hours."

7. A nurse is assessing a school-age child who has peritonitis. Which of the following find- ings should the nurse expect? A. Hyperactive bowel sounds B. Abdominal disten- tion C. Bradycardia D. Bloody stool of 15 for children. The parent should apply sun- screen prior to sun exposure to reduce the risk of sunburn. B. Abdominal distention Rationale: The nurse should identify that abdomi- nal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdom- inal distention. Other manifestations include chills, irritability, and restlessness.

personalized success A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse iden- tify as a manifestation of increased intracra- nial pressure? A. Hypotension B. Reports insomnia C. Difficulty concen- trating D. Tachycardia

9. A nurse in an emer- gency department is performing a physi- cal assessment on a 2 - week-old male new- born. Which of the fol- lowing findings is the priority for the nurse to report to the provider? A. Excoriated scrotal area B. Multiple capillary he- mangiomas C. Depressed posterior fontanel C. Difficulty concentrating Rationale: The nurse should identify that irritability, inability to follow commands, and difficulty concen- trating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem. D. Substernal retractions Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indi- cates the newborn is experiencing increased respi- ratory effort, which could quickly progress to respi- ratory failure.

personalized success D. Substernal retrac- tions

10. A nurse is caring for an infant who has res- piratory syncytial virus (RSV). Which of the fol- lowing actions should the nurse implement for infection control? A. Have a designated stethoscope in the in- fant's room. B. Place the infant in a room equipped with negative airflow. C. Administer Palivizumab as pre- scribed for the infant. D. Remove gloves af- ter leaving the infant's room.
11. A hospice nurse is car- ing for a preschool- er who has a termi- nal illness. One of the preschooler's parents tells the nurse that they cannot cope any- more and are think- ing about moving out of the house. Which of the following state- ments should the A. Have a designated stethoscope in the infant's room. Rationale: The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as blood pressure cuff and stethoscope, should be placed in the infant's room. D. "Let's talk about some of the ways you have handled previous stressors in your life." Rationale: This statement offers a general lead to allow the parent to express their feelings and previ- ous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.

personalized success nurse make? A. "It is important that you provide emotional support for your family at this time." B. "You have to do what you feel is best. Every- thing will turn out fine." C. "I know how you feel. This is an extremely stressful time for your family." D. "Let's talk about some of the ways you have handled previous stressors in your life."

12. A nurse is preparing to collect a sample from a toddler for a sick- le-turbidity test. Which of the following actions should the nurse plan to take? A. Obtain a sputum specimen. B. Perform an Allen test. C. Perform a finger stick. C. Perform a finger stick Rationale: The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophore- sis is required to distinguish between children who have the genetic trait and children who have the disease.

personalized success D. Obtain a stool speci- men

13. A nurse is monitoring the oxygen saturation level of an infant us- ing pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? A. Wrist B. Great toe C. Index finger D. Heel
14. A nurse is caring for a school-age child who has peripheral ede- ma. The nurse should identify which of the following assessments should be performed to confirm peripheral ede- ma. A. Palpate the dorsum of the child's feet. B. Weigh the child daily using the same scale. C. Assess the child's skin turgor. B. Great toe Rationale: The nurse should secure the sensor to the great toe of the infant and then place a snug-fit- ting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse. A. Palpate the dorsum of the child's feet. Rationale: The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema.

personalized success D. Observe the child for periorbital swelling.

15. A nurse is reviewing the laboratory report of an infant who is receiv- ing treatment for se- vere dehydration. The nurse should identify which of the following laboratory values indi- cates the effectiveness of the current treat- ment. A. Potassium 2. mEq/L B. Sodium 140 mEq/L C. Urine specific gravi- ty 1. D. BUN 25 mg/dL
16. A nurse is assessing a school-age child who has meningitis. Which of the following find- ings is the priority for the nurse to report to the provider? A. Reports HA as 6 on a scale of 0 to 10 B. Petechiae on the lower extremities B. Sodium 140 mEq/L Rationale: The nurse should identify that a sodium level of 140 mEq/L is within the expected range of 134 to 150 mEq/L and indicate the current treatment regimen the infant is receiving for dehydration is effective. B. Petechiae on the lower extremities Rationale: The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.

personalized success C. Nuchal rigidity D. Positive Kernig's sign

17. A school nurse is preparing to admin- ister Atomoxetine 1. mg/kg/day PO to a school-age child who weighs 75 lb. Avail- able is Atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the an- swer to the nearest whole number. Use a leading zero if it ap- plies. Do not use a trail- ing zero).
18. A nurse is planning care for a school-age child who is in the olig- uric phase of acute kid- ney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interven- tions should the nurse include in the plan? A. Administer Ibu to the child for a temperature greater than 38 C (100. F). B. Assess the child's 1 capsule D. Initiate seizure precautions for the child. Rationale: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.

personalized success BP every 8 hr. C. Weigh the child weekly at various times of the day. D. Initiate seizure pre- cautions for the child.

19. A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifes- tations should alert the nurse to a possible he- molytic transfusion re- action? A. Laryngeal edema B. Flank pain C. Distended neck veins D. Muscular weakness
20. A nurse is planning developmental activi- ties for a newly admit- ted 10-year-old child who has neutropenia. Which of the follow- ing actions should the nurse plan to take? A. Provide the child with a book about ad- B. Flank pain Rationale: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. A. Provide the child with a book about adventure. Rationale: The nurse should provide a school-age child with a book about adventure as a devel- opmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel pow- erful and skillful as they imagine themselves in the stories they read.

personalized success venture. B. Arrange frequent visits from family mem- bers and peers. C. Give the child a large piece puzzle. D. Use puppets to en- tertain the child.

21. A nurse is assessing a 3 - year-old toddler at a well-child visit. Which of the following man- ifestations should the nurse report to the provider? A. BP 90/30 mmHg B. RR 45/min C. Weight 14.5 kg (32 lb) D. HR 110/min
22. A nurse is planning care to address the nutritional needs of a preschooler who has CF. Which of the following interventions should the nurse in- clude in the plan? A. Administer pancre- atic enzymes 2 hr after B. RR 45/min Rationale: The nurse should identify that a RR of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory dis- tress. Therefore, the nurse should report this finding to the provider. D. Increase fat content in the child's diet to 40% of total calories. Rationale: A child who has CF is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake.

personalized success meals. B. Discontinue the use of pancreatic enzymes if steatorrhea devel- ops. C. Limit fluid intake 750 mL per day. D. Increase fat content in the child's diet to 40% of total calories.

23. A nurse is caring for a toddler who has acute otitis media and a tem- perature of 40 C ( F). After administering Acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? A. Apply a cooling blanket to the toddler. B. Dress the toddler in minimal clothing. C. Give the toddler a tepid bath. D. Administer Diphen- hydramine to the tod- dler. B. Dress the toddler in minimal clothing. Rationale: The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature.

personalized success A school nurse is assessing an adoles- cent who has multiple burns in various stages of healing. Which of the following behav- iors should the nurse identify as a possible indication of physical abuse? A. Expresses a reluc- tance to leave home B. Provides a detailed description of how the burns occurred C. Denies discomfort during assessment of injuries D. describes strong re- lationships with peers

25. A nurse is preparing to administer Ibu 5 mg/kg every 6 hr PRN for a temperature above 38.0 C (100.5 F) to an infant who weighs 17.6 lb. Available is Ibu oral suspension 100 mg/5 mL. How many mL should the nurse administer to the infant per dose? (Round the answer to the nearest whole number. Use a C. Denies discomfort during assessment of injuries Rationale: The nurse should suspect child maltreat- ment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury. 2 mL

personalized success leading zero if it ap- plies. Do not use a trail- ing zero).

26. A nurse is caring for a school-age child who is receiving Cefazolin via intermittent IV bo- lus. The child suddenly develops diffuse flush- ing of the skin and angioedema. After dis- continuing the medica- tion infusion, which of the following medica- tions should the nurse administer first? A. Prednisone B. Epinephrine C. Diphenhydramine D. Albuterol
27. A nurse in a provider's office is caring for a school-age child who has varicella. The par- ent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? A. "When your child no longer has an in- B. Epinephrine Rationale: This child is most likely experiencing an anaphylactic reaction to Cefazolin. According to evi- dence-based practice, the nurse should first admin- ister Epi to treat anaphylaxis. Epi is a beta-adrener- gic agonist that stimulates the heart, causes vaso- constriction of blood vessels in the skin and mu- cous membranes, and triggers bronchodilation in the lungs. C. "When your child's lesions are crusted, usually 6 days after they appear." Rationale: The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usu- ally takes about 6 days.

personalized success creased temperature." B. "Three days after you first noticed the rash appear on your child." C. "When your child's lesions are crusted, usually 6 days after they appear." D. "Two to three weeks, when your child's le- sions completely dis- appear."

28. A nurse is reviewing the lumbar puncture results of a school-age child who is suspect- ed of having bacteri- al meningitis. Which of the following findings should the nurse iden- tify as an indication of bacterial meningitis? A. Decreased cere- brospinal fluid pres- sure B. Decreased WBC count C. Increased protein concentration C. Increased protein concentration Rationale: The nurse should identify that an in- creased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.

personalized success D. Increased glucose level

29. A school nurse is car- ing for a child following a tonic-clonic seizure. Which of the follow- ing actions should the nurse take first? A. Check the child for a head injury. B. Observe for oral bleeding. C. Check the child's respiratory rate. D. Observe for extremi- ty weakness.
30. A nurse is caring for a preschooler who has CHF. The nurse ob- serves wide QRS com- plexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clari- fy with the provider? A. Furosemide B. Captopril C. Regular insulin C. Check the child's respiratory rate. Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to asses the child's RR. If the child is not breathing the nurse should administer rescue breaths. D. Potassium chloride Rationale: The nurse should identify that a child who has CHF can develop electrolyte imbalances such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride which can in- crease the severity of hyperkalemia.

personalized success D. Potassium chloride

31. A nurse is provid- ing discharge teach- ing to the parent of a school-age child who has moderate persis- tent asthma. Which of the following instruc- tions should the nurse include? A. "You should give your child their Sal- meterol inhaler every 4 hours when they are having an acute episode of wheezing." B. "You should moni- tor your child's weight weekly while they are receiving inhaled corti- costeroid therapy." C. "Pulmonary func- tion tests will be per- formed every 12 to 14 months to evaluate how your child is re- sponding to therapy." D. "When using the peak expiratory flow meter, record your child's average of three readings." C. "Pulmonary function tests will be performed every 12 to 14 months to evaluate how your child is re- sponding to therapy." Rationale: The nurse should inform the parent that their child will need PFTs every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly.

personalized success

32. A school nurse is pro- viding an in-service for faculty about improv- ing education for stu- dents who have ADHD. Which of the following statements by a facul- ty member indicates an understanding of the teaching? A. "I will plan to increase the amount of homework I assign to students who have ADHD." B. "I will give students who have ADHD the same amount of time as other students to complete tests." C. "I will allow students who have ADHD one rest breast throughout the day." D. "I will teach chal- lenging academic sub- jects to students who have ADHD in the morning."
33. A nurse is caring for a toddler who is ex- periencing acute diar- rhea and has moder- ate dehydration. Which D. "I will teach challenging academic subjects to students who have ADHD in the morning." Rationale: Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective. D. Oral rehydration solution Rationale: A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorp-

personalized success of the following nutri- tional items should the nurse offer to the tod- dler? A. Apple juice B. Peanut butter C. Chicken broth D. Oral rehydration so- lution

34. A nurse is receiving a change of shift report for four children. Which of the following chil- dren should the nurse assess first? A. An adolescent who was placed in halo trac- tion 1 hr ago and re- ports pain as 6 on a scale of 0 to 10 B. An adolescent who has infective endo- carditis and reports having a HA C. A toddler who has a concussion and is ex- periencing an episode of forceful vomiting D. A school-age child who has tion of water and sodium. This promotes recovery from dehydration. C. A toddler who has a concussion and is experienc- ing an episode of forceful vomiting Rationale: When using the urgent vs non-urgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.

personalized success acute glomeru- lonephritis and brown-colored urine

35. A nurse is review- ing the laboratory re- port of a 7-year-old child who is receiving chemotherapy. Which of the following lab- oratory values should the nurse report to the provider? A. Hgb 8.5 g/dL B. WBC count 9,500/mm3 C. Prealbumin 18 mg/dL D. Platelets 300,000/mm3
36. A nurse is teaching the parent of an in- fant about ways to prevent sudden unex- plained infant death (SUID). Which of the following instructions should the nurse in- clude? A. "Place the infant in a prone position to sleep." A. Hgb 8.5 g/dL Rationale: A child receiving chemotherapy is at risk for anemia due to the chemotherapy's effects on the blood-forming cells of the bone marrow. The devel- opment of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7 - year-old child and should be reported to the provider. D. "Give the infant a pacifier at bedtime." Rationale: The nurse should inform the parent that protective factors against SUID include breastfeed- ing and the use of a pacifier when the infant is sleeping.

personalized success B. "Allow the infant to sleep on a large pil- low." C. "Use a soft mattress in the infant's crib." D. "Give the infant a pacifier at bedtime."

37. NGN* A nurse in an emergency depart- ment is caring for a 4 - year-old child who was rescued from a home fire by emer- gency medical ser- vices (EMS). The nurse should iden- tify which of the follow- ing findings require im- mediate follow-up. Se- lect the 3 findings that require immediate fol- low-up. A. Child is awake and crying B. Partial, and full-thickness burns to the left upper anteri- or chest and anterior neck C. Non-productive cough B. Partial, and full-thickness burns to the left upper anterior chest and anterior neck Rationale: Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate f/u due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. D. SaO2 89% on room air Rationale: Airway, breathing, and circulation are the immediate concerns. The nurse should immediately f/u on the low oxygen saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. E. Heart rate 150/min Rationale: Airway, breathing, and circulation are the immediate concerns. The nurse should immediately f/u on the child's increased HR. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock d/t fluid loss.

personalized success D. SaO2 89% on room air E. Heart rate 150/min F. Temperature 37.7 C (99.9 F) G. Blood pressure 100/52 mmHg

38. NGN* A nurse in an emergency depart- ment is caring for a 4 - year-old child who was rescued from a home fire by emer- gency medical ser- vices (EMS). Which of the following potential provider pre- scriptions should the nurse identify as an- ticipated or contraindi- cated? For each poten- tial provider's prescrip- tion, click to specify if the potential provider's prescription is antici- pated or contraindicat- ed for the child. Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas. Insert indwelling uri- Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas is contraindicated. Rationale: Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. The nurse should cover the burn with a clean, dry cloth to prevent contami- nation and hypothermia. Insert indwelling urinary catheter is anticipated. Rationale: Inserting an indwelling urinary catheter is essential and allows for accurate measurement of urine output. Urine output is an indicator of the fluid status of the child. A child who has major burns will lose a significant amount of fluid due to increased capillary permeability, which increases the risk for hypovolemic shock. It is important to maintain accu- rate hourly I&O to manage fluid replacement. Provide 100% oxygen via face mask is anticipated. Rationale: Upon admission to the emergency de- partment, the nurse should recognize the need to provide 100% oxygen via face mask as an essential prescription. The child's SaO2 is below the expected reference range their RR is increased.

personalized success nary catheter. Provide 100% oxygen via face mask. Weight the child.

39. NGN* The nurse is car- ing for the child 4 days after admission. After reviewing the child's assessment, which of the follow- ing findings should the nurse address first? Complete the following sentence by using the lists of options. Dropdown 1: Temperature Saturated dressing Urine output BP Respiratory status Dropdown 2: Pain Sensorium Nutrition Drainage on dressing Fluid status
40. NGN* The nurse is con- tinuing to care for the child. Weigh the child is anticipated. Rationale: The nurse should recognize the need to weigh the child as an essential. Children of the same age weigh different amounts. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight. Dropdown 1: Temperature Rationale: When using the urgent vs nonurgent ap- proach to client care, the nurse should determine that an increased temperature is a priority finding because it can indicate an infection and sepsis. Wound sepsis is most likely to occur between the third and fifth day after a burn. Therefore, the nurse should first address the child's temperature. Dropdown 2: Pain Rationale: When using the urgent vs nonurgent ap- proach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing. Change the morphine route to family-controlled analgesia via a PCA pump is anticipated. Rationale: A pain rating of 8 indicates severe pain.

personalized success After examining the child during hydrother- apy, the provider en- ters prescriptions into the child's medical record. For each poten- tial provider's prescrip- tion, click to specify if the potential prescrip- tion is anticipated or contraindicated for the child. Change the morphine route to family-con- trolled analgesia via a PCA pump. Obtain a wound cul- ture. Place the child on a pressure-reduction mattress. Limit daily protein in- take.

41. NGN* The nurse is car- ing for the child 14 days after admission. The child has returned to the unit following the procedure. Which of the following actions should the nurse take? SATA the use of a PCA pump should increase the ef- fectiveness of pain management during movement and procedures. The nurse should teach the child's primary caregiver about the use of the PCA pump. Obtain a wound culture is anticipated. Rationale: The child has an elevated temperature and malodorous green wound drainage. The nurse should obtain a wound culture to determine the causative organism and an abx should be admin- istered. Place the child on a pressure-reduction mattress is anticipated. Rationale: The child has developed a stage 1 pres- sure injury on their occiput. A pressure-reduction mattress can help prevent further tissue injury. Limit daily protein intake is contraindicated. Rationale: Children who have major burns require a high-protein, high-calorie diet to help with wound healing. The nurse should provide high-protein snacks to the child between meals. B. Provide 100% oxygen via face mask. Rationale: The nurse should provide 100% oxygen via a face mask to the child because of their SaO2 and RR. The SaO2 should be maintained at 95% or higher and if the SaO2 falls below 95%, supplemen- tal oxygen should be initiated. C. Check anterior neck and chest dressing for bleed- ing.