A nurse is planning to obtain a rectal temperature from a toddler. Which of the following actions should the nurse take?

Insert the tip of the thermometer 5 cm (2 in) into the rectum.

Place the child in prone position.

Stabilize the thermometer at the distal end.

Direct the tip of the thermometer toward the spine during insertion.

None

Answer and Explanation

The Correct Answer is B

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Correct Answer is B

Explanation

A. "Administer the medication on an empty stomach." Phenytoin can be taken with or without food. Administering with food can reduce stomach upset.
B. "Encourage the child to brush their teeth after each meal." Phenytoin increases the risk of gingival hyperplasia, so regular brushing helps maintain oral hygiene and prevents complications.
C. "Crush the child's medication to mix with applesauce." Extended-release capsules should not be crushed as this alters their intended release mechanism.
D. "Observe the child for diarrhea." Diarrhea is not a common side effect of phenytoin. Monitoring should focus on side effects like gingival overgrowth, nystagmus, or skin rashes.

A. Elevate the child's residual limb for 48 hr. B. Apply a loose-fitting bandage onto the child's residual limb. C. Perform active and isotonic range-of-motion exercises. D. Clean the incision using half-strength hydrogen peroxide every 8 hr.

Correct Answer is C

Explanation

A. Elevate the child's residual limb for 48 hr. Elevation for prolonged periods can cause flexion contractures. Elevation is typically limited to the first 24 hours, if at all.
B. Apply a loose-fitting bandage onto the child's residual limb. A compression bandage, not loose-fitting, is used to shape the residual limb and reduce swelling.
C. Perform active and isotonic range-of-motion exercises. These exercises prevent contractures and maintain muscle strength.
D. Clean the incision using half-strength hydrogen peroxide every 8 hr. Hydrogen peroxide can damage healthy tissue and delay healing. Saline or antiseptic solutions are preferred.

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A nurse is planning to obtain a rectal temperature from a toddler. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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