A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever.

Which of the following responses should the nurse make?

"You should follow the label directions based on your child's weight."

"You should avoid administering aspirin to your child."

"Your child will require an antibiotic if she develops a fever."

"Your child can have two baby aspirins every 4 hours."

Answer and Explanation

The Correct Answer is B

A.   "You should follow the label directions based on your child's weight." While dosing according to weight is a common practice for many medications, it's essential to emphasize the importance of avoiding aspirin in children due to the risk of Reye's syndrome, a rare but serious condition associated with aspirin use in viral illnesses.
B.   "You should avoid administering aspirin to your child." This response is correct because the use of aspirin in children, especially during viral infections, can increase the risk of Reye's syndrome, a severe condition that affects the brain and liver.
C.   "Your child will require an antibiotic if she develops a fever." Antibiotics are not typically

indicated for fever unless the fever is caused by a bacterial infection. It's important to address the parent's question about managing fever specifically.
D. "Your child can have two baby aspirins every 4 hours." This response is incorrect and potentially harmful. Aspirin should not be given to children due to the risk of Reye's syndrome.

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Correct Answer is A

Explanation

A. An elevated serum calcium level (hypercalcemia) can indicate a complication of total parenteral nutrition, such as hypercalcemia resulting from excess calcium supplementation in the
TPN solution, which can lead to complications such as renal calculi and cardiac dysrhythmias.
B. The blood urea nitrogen (BUN) level within the normal range does not indicate a complication related to total parenteral nutrition.
C. The serum potassium level within the normal range does not indicate a complication related to total parenteral nutrition.
D. A normal white blood cell (WBC) count does not indicate a complication related to total parenteral nutrition.

A. The client's most recent blood pressure reading was 110/60 mm Hg. B. The client's morning laboratory results included a potassium level of 4.9 mg/dL. C. The client has 2 pitting edema in the lower extremities. D. The client's partner assisted them with their meal tray.

Correct Answer is C

Explanation

A. While the blood pressure reading provides information about the client's cardiovascular status, it does not specifically indicate the severity of heart failure. Therefore, it is not the most pertinent information to include in the report.
B. The potassium level is important to monitor in clients with heart failure due to the potential for electrolyte imbalances, but a specific potassium level of 4.9 mg/dL may not be immediately relevant to the client's current status. Therefore, it is not the most critical information to include in the report.

C. Pitting edema in the lower extremities is a common finding in clients with heart failure and can indicate fluid overload, a hallmark characteristic of heart failure. Including this information in the report is essential for providing an accurate picture of the client's condition and current status.
D. While assistance with meals may provide insight into the client's functional status and support system, it is not as directly related to the client's heart failure as the presence of pitting edema.

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A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?

Nursing Test Bank

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A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever.

Which of the following responses should the nurse make?