A nurse is reviewing the medication record of an infant. The nurse notes a new prescription for acetaminophen 80 mg PO for a temperature above 38.5° C (101.3° F). Which of the following should the nurse clarify with the provider before administering the medication?

Indication

Frequency

Route

Dose

Answer and Explanation

The Correct Answer is B

A. Indication: The prescription clearly states that acetaminophen is to be administered for a temperature above 38.5°C (101.3°F), which provides an appropriate therapeutic indication. Fever reduction is a standard and evidence-based use of acetaminophen in infants. The indication is specific and does not require clarification.

B. Frequency: The order includes the medication name, dose, route, and indication but does not specify how often the medication can be administered. Acetaminophen requires clear dosing intervals, typically every 4 to 6 hours, with a maximum daily dose to prevent hepatotoxicity. Without a defined frequency, there is a risk of overdose or inappropriate administration timing.

C. Route: The prescription specifies oral administration (PO), which is an appropriate and commonly used route for acetaminophen in infants who can tolerate oral intake. There is no ambiguity regarding how the medication should be delivered.

D. Dose: An 80 mg dose may be appropriate depending on the infant’s weight, as pediatric acetaminophen dosing is calculated at 10–15 mg/kg per dose. Although weight-based dosing should always be verified, the presence of a specific dose does not automatically require clarification unless it falls outside the safe range.

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Correct Answer is A

Explanation

A. Serve meals with plastic utensils: Clients who have attempted suicide are at risk of self-harm. Using plastic utensils reduces the risk of injury from sharp objects and is an immediate safety intervention to prevent further attempts. This is a standard precaution in suicide precautions.

B. Assign another client to accompany the client to therapy sessions: Clients at risk for suicide should be supervised by staff, not other clients. Relying on peers does not ensure safety and may place both clients at risk, making this an inappropriate intervention.

C. Assign the client to a private room: While privacy can provide comfort, placing a high-risk client in a private room without adequate observation increases the risk of unnoticed self-harm. Clients at risk for suicide require close monitoring and a safe environment with staff visibility.

D. Check on the client every 4 hr: Suicide precautions require frequent observation, often continuous or at least every 15–30 minutes depending on risk level. Checking every 4 hours is insufficient and does not adequately ensure client safety.

A. Mastitis B. Engorgement C. Blocked milk duct D. Thrush

Correct Answer is A

Explanation

A. Mastitis: Mastitis is an infection of the breast tissue, often caused by bacteria entering through a cracked nipple. It presents with localized redness, warmth, tenderness, swelling, and systemic symptoms such as fever and chills. These signs align with the client’s sudden onset of chills and a tender, red area on the breast, indicating an acute infectious process.

B. Engorgement: Engorgement occurs when the breasts are overfilled with milk, leading to generalized swelling, firmness, and mild discomfort. It usually develops gradually rather than suddenly and is not associated with systemic symptoms like chills or fever.

C. Blocked milk duct: A blocked duct can cause localized firmness and tenderness, often forming a small, palpable lump. Unlike mastitis, it typically does not produce systemic symptoms such as chills or fever, and the redness is usually limited to the area over the blockage rather than indicating infection.

D. Thrush: Thrush is a fungal infection caused by Candida species, affecting the nipple or infant’s mouth. It presents with pain during breastfeeding, itching, or burning, and may show white patches on the nipple or tongue. Thrush does not cause localized redness, tenderness, or systemic symptoms such as chills.

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A nurse is reviewing the medication record of an infant. The nurse notes a new prescription for acetaminophen 80 mg PO for a temperature above 38.5° C (101.3° F). Which of the following should the nurse clarify with the provider before administering the medication?

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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