A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?

Infuse normal saline intravenously.

Apply external cooling blanket.

Provide a bottle of electrolyte solution.

Administer an antipyretic rectally.

Answer and Explanation

The Correct Answer is A

A. Infusing normal saline intravenously is crucial as the infant shows signs of dehydration (weak cry, no tears), and intravenous fluids are necessary to restore hydration and electrolyte balance.

B. Applying an external cooling blanket may be necessary to manage fever but does not address the dehydration issue.

C. Providing an electrolyte solution is helpful, but given the infant’s refusal to drink, IV fluids are more immediate and effective.

D. Administering an antipyretic rectally might help manage fever but does not address the dehydration or fluid needs.

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Correct Answer is C

Explanation

A. Outreach for support groups is more related to secondary or tertiary prevention.

B. Blood pressure screening is a form of secondary prevention, aimed at early detection and intervention.

C. Immunizations are a form of primary prevention, aimed at preventing disease before it occurs.

D. Domestic violence assistance is a crucial service but does not directly relate to primary disease prevention.

A. Attach the client to a cardiorespiratory monitor to measure the respiratory rate B. Assure that the blood pressure cuff is the right size C. Alert the healthcare provider once the abnormal finding is confirmed D. Retake the temperature orally E. Reassess the blood pressure F. Measure the heart rate for a full 60 seconds

Correct Answer is ["C","D","F"]

Explanation

A. Attach the client to a cardiorespiratory monitor to measure the respiratory rate: The respiratory rate is within the normal range and does not require continuous monitoring at this stage unless other symptoms suggest deterioration.

B. Assure that the blood pressure cuff is the right size: The blood pressure is within normal limits and does not indicate an issue with the cuff size at this moment.

C. Alert the healthcare provider once the abnormal finding is confirmed: A temperature of 102.1° F (38.9° C) is a significant fever and could indicate worsening infection or an adverse reaction to the medication. Alerting the healthcare provider is essential for prompt evaluation and treatment adjustment.

D. Retake the temperature orally: Confirming the elevated temperature with a retake is crucial for accuracy. Temperature readings can sometimes be affected by factors like improper thermometer use or external influences.

E. Reassess the blood pressure: Blood pressure readings are stable and not indicative of any immediate issue requiring reassessment.

F. Measure the heart rate for a full 60 seconds: The heart rate of 62 beats/minute is on the lower side of normal, and measuring for a full minute will provide a more accurate assessment of the client’s heart rate and detect any irregularities.

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A male infant with a 2-day history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

Correct Answer is C

Explanation

Correct Answer is ["C","D","F"]

Explanation

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