A nurse is providing teaching about home care to a parent of a 3-year-old child who has a fever. Which of the following instructions should the nurse include in the teaching?

Apply a light blanket if the child begins to shiver.

Wake the child every 4 hr during the night to drink 118.3 mL (4 oz) of apple juice.

Take the child's temperature every 10 min after administering acetaminophen.

Place ice packs on the child's armpits and groin.

Answer and Explanation

The Correct Answer is A

A. "Apply a light blanket if the child begins to shiver." Shivering can increase body temperature, so a light blanket can provide comfort while preventing excessive heat retention. Over-bundling should be avoided.

B. "Wake the child every 4 hr during the night to drink 118.3 mL (4 oz) of apple juice." Encouraging fluid intake is important, but waking a sleeping child is unnecessary unless there are concerns about dehydration. Instead, fluids should be offered frequently while the child is awake.

C. "Take the child's temperature every 10 min after administering acetaminophen." Checking the temperature this frequently is not necessary and could cause unnecessary stress for the child. Acetaminophen typically takes 30–60 minutes to take effect, so temperature checks should be spaced appropriately.

D. "Place ice packs on the child's armpits and groin." Using ice packs can cause shivering, which increases body temperature. Instead, cooling measures like a lukewarm sponge bath or removing excess clothing are preferred.

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Correct Answer is C

Explanation

A. Perform gastric lavage with activated charcoal. Activated charcoal is most effective if given within 1 hour of ingestion. Since the ingestion occurred 4 hours ago, activated charcoal would not be beneficial.
B. Begin hemodialysis within the next 24 hr. Hemodialysis is only used in severe cases of acetaminophen toxicity with liver failure, which is not indicated at this stage.
C. Prepare to give oral N-acetylcysteine. N-acetylcysteine (NAC) is the antidote for acetaminophen overdose and should be administered as soon as possible within 8 to 10 hours after ingestion to prevent liver damage.
D. Send the child home on increased fluid intake. Acetaminophen overdose can cause severe liver toxicity, so treatment in a medical setting is required, not just increased fluids at home.

A. Neurologic assessment B. Hemoglobin C. Peripheral pulses D. WBC E. Glucose F. Abdominal assessment G. Pain assessment H. Temperature

Correct Answer is ["A","B","D","F","H"]

Explanation

A. Neurologic assessment. Neurologic changes can indicate worsening infection, sepsis, or other serious conditions, requiring immediate follow-up.

B. Hemoglobin. The child's hemoglobin level (9.5 g/dL) is below the normal range (10 to 15.5 g/dL), indicating anemia, which requires monitoring and possible intervention.

C. Peripheral pulses. There is no indication of circulatory compromise or perfusion issues in the given data.

D. WBC. The elevated WBC count (14,000 mm³) suggests an active infection or inflammation, which requires immediate follow-up.

E. Glucose. The glucose level (90 mg/dL) is within normal limits and does not require immediate attention.

F. Abdominal assessment. If the child has an infection, especially a serious bacterial infection, monitoring for abdominal distension, tenderness, or signs of peritonitis is crucial.

G. Pain assessment. While pain assessment is always important, it does not require immediate follow-up unless there are specific pain-related concerns in the provided data.

H. Temperature. Fever is a key sign of infection. Monitoring the child’s temperature is crucial in identifying worsening infection or sepsis.

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A nurse is providing teaching about home care to a parent of a 3-year-old child who has a fever. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a child who weighs 18 kg (39.7 lb) and ingested six 500 mg acetaminophen tablets 4 hr ago. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is ["A","B","D","F","H"]

Explanation

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