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:
Administering digoxin should be based on the infant's specific heart rate and the healthcare provider's prescription, rather than a specific pulse value.
Choice B reason:
Allowing for frequent rest periods is important for an infant with heart failure, as it helps conserve energy and reduce cardiac workload.
Choice C reason:
Feeding duration should be based on the infant's tolerance and ability to feed effectively, rather than a specific time frame.
Choice D reason:
Maintaining the infant in a supine position can help with respiratory function but should be balanced with appropriate positioning to prevent aspiration and promote comfort. It is not the sole action to include in the plan of care.
Correct Answer is C
Explanation
Choice A reason:
Reducing fiber intake is not necessary for a client in skeletal traction. Maintaining a balanced diet, including fiber, is important for overall health.
Choice B reason:
The nurse should not lift the traction weights off the floor. The weights must hang freely to provide the necessary traction.
Choice C reason:
Performing passive range-of-motion exercises helps prevent stiffness and muscle atrophy in the affected extremity. This is an important nursing intervention for a client in skeletal traction.
Choice D reason:
Applying protective padding to the pin sites is essential to prevent pressure and irritation. However, this action alone does not address the need for range-of-motion exercises.
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