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 D

Explanation

A. Administer IV antibiotics: While urgent, antibiotics can be administered after precautions are in place to ensure safety.
B. Monitor vital signs: Important but not the first action. Vital signs can be monitored after precautions are initiated.
C. Encourage oral fluids: Incorrect because IV fluids are usually required due to the severity of the illness and risk of shock.
D. Initiate droplet precautions. Protecting others from transmission is the highest priority in managing bacterial meningitis, a highly contagious condition.

A. Warm extremities B. Frequent headaches C. Distended neck veins D. Weight loss

Correct Answer is C

Explanation

A. Warm extremities: Typically, in heart failure, extremities can feel cold due to poor circulation and reduced cardiac output.
B. Frequent headaches: Headaches are not a typical sign of heart failure in children. Although they can occur in some cases due to increased intracranial pressure, they are not characteristic of heart failure.
C. Distended neck veins: Distended neck veins are a hallmark sign of right-sided heart failure. It occurs when the heart is unable to efficiently pump blood, leading to congestion and fluid retention, which can cause blood to back up into the veins, resulting in visible distention.
D. Weight loss: Weight gain due to fluid retention is more common in heart failure. Weight loss may occur in more advanced or chronic cases due to decreased appetite and fluid shifts, but weight gain is the expected finding in early stages.

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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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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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