NCLEX Practice Question of the Day

The nurse caring for a child burned over 20% of her body assists the physician in performing dressing changes on day 5 after the initial injury. The child appears disoriented, has a fever of 101º F (38.3º C), and is crying in pain. Which of the following nursing interventions would be the MOST appropriate in caring for this client?

Category: Non-pharmacological comfort interventions

1. The nurse would gather equipment, but not before addressing the crying child.
2. CORRECT: The child may be suffering from an infection. The nurse recognizes that disorientation and fever are the first signs of sepsis in burn clients. It would be most appropriate to assess for the causes of fever and pain and notify the physician before proceeding.
3. Analgesics may be appropriate but not before assessing the pain and source of fever and disorientation.
4. Distractions may be offered after the assessment but they do not take priority over notifying the physician regarding the findings about the source of fever and pain.

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