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A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

Give 500 mg acetaminophen PO every 2 hr.

Administer a 300-mg aspirin suppository.

Place the child in an ice bath.

Lower the temperature of the room.

Answer and Explanation

The Correct Answer is D

Choice A reason:

This is a high dose for a 2 year old child.

Choice B reason:

Aspirin is contraindicated for children with viral infections due to the risk of Reye's syndrome. It should not be administered.

Choice C reason:

Placing the child in an ice bath is an overly aggressive intervention and can lead to hypothermia. It is not recommended.

Choice D reason:

Lowering the temperature of the room is important in reducing external temperature to help cool the baby.

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

Explanation

Choice A reason:

Obtaining the infant's weight with their diaper on should be avoided as this can alter the result.

Choice B reason:

Placing a stadiometer on the top of the infant's head to measure their length can harm or distress the infant.

Choice C reason:

Ensuring the scale is at 0 is important in obtaining an accurate weight Choice D reason:

Covering the scale with paper is recommended for hygiene purposes

Choice E reason:

This method provides an accurate measurement of the infant's length.

A. Place a urine collection device on the infant until the specimen is obtained. B. Obtain the specimen by swabbing the infant's rectum using a sterile culture swab. C. Maintain the specimen at room temperature after collection until it is transferred to the lab. D. Transfer the specimen to the collection container using povidone-iodine-soaked gauze.

Correct Answer is B

Explanation

Choice A reason:

Placing a urine collection device on the infant is not an appropriate method for collecting a stool specimen.

Choice B reason:

Obtaining the specimen by swabbing the infant's rectum using a sterile culture swab is the correct method for collecting a stool specimen from an infant.

Choice C reason:

Maintaining the specimen at room temperature is appropriate after collection until it is transferred to the lab. This is standard procedure for many specimens.

Choice D reason:

Using povidone-iodine-soaked gauze is not a standard method for transferring a stool specimen to the collection container.

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A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

Nursing Test Bank

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