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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Mucosal ulceration – This is an acute side effect of radiation therapy, not a late adverse effect.
B. Nausea – Nausea is a short-term side effect that occurs during or shortly after radiation therapy.
C. Desquamation – Skin peeling (desquamation) is a common acute reaction to radiation but is not considered a late effect.
D. Short stature – Radiation therapy in young children can affect growth, particularly if the brain or spine is irradiated. Damage to the pituitary gland can lead to growth hormone deficiency, resulting in delayed growth and short stature, which are considered late effects of radiation therapy.
Correct Answer is D
Explanation
A. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
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