A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are both partial- and full-thickness burns
The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which of the following will be prescribed initially? 1. Insertion of a Foley catheter
2. Insertion of a nasogastric tube
3. Administration of an anesthetic agent for sedation
4. Application of an antimicrobial agent to the burns
1
Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be accu-rately measured on an hourly basis. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed after assessment, but this would not be the initial action. IV fluids are administered at a rate suf-ficient to keep the child's urine output at 1 to 2 mL/kg of body weight per hour for children weighing less than 30 kg, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required but would not be the priority intervention.
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