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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
A weight loss of 0.25 kg (0.55 lb) may be within the range of normal fluctuation for an infant and may not necessarily warrant immediate reporting. However, it should be monitored closely.
Choice B reason:
Vomiting twice in 4 hours after receiving digoxin is a concerning finding. Digoxin has a narrow therapeutic range, and vomiting can lead to potential overdose. This should be reported to the provider for further evaluation.
Choice C reason:
A respiratory rate of 30/min may indicate increased work of breathing, which is a concern in an infant with heart failure. However, it is not specific to digoxin administration and may require
intervention but not immediate reporting.
Choice D reason:
A heart rate of 130/min is within the range of normal for an infant, especially one with heart failure. This finding is not specific to digoxin administration and may not warrant immediate reporting.
Correct Answer is D
Explanation
Choice A reason:
Avoiding discussing the child's diagnosis with the sibling may create unnecessary secrecy and could hinder the sibling's understanding and coping.
Choice B reason:
Designating one parent to stay at home with the sibling may not be necessary, as both parents can still provide support and care for both children.
Choice C reason:
Avoiding having the sibling visit the child in the facility may isolate them and prevent opportunities for bonding and support.
Choice D reason:
This statement is correct. Encouraging phone calls between the siblings allows them to maintain communication, express their feelings, and support each other during the separation caused by hospitalization.
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