A pre-school age child is admitted with a febrile seizure. The practical nurse (PN) obtains an oral temperature of 104.2° F (40.1° C) during the morning assessment. Which action should the PN prepare to implement?
Provide a tepid sponge bath.
Remove blankets while shivering.
Apply blankets during diaphoresis.
Turn on an oscillating fan.
The Correct Answer is A
A. Provide a tepid sponge bath: Providing a tepid sponge bath is an effective non-pharmacological intervention to help lower a dangerously high fever in a child. This method promotes gentle cooling by encouraging heat loss through evaporation, helping reduce the risk of another seizure without causing abrupt temperature changes.
B. Remove blankets while shivering: Removing blankets while the child is actively shivering is not recommended because shivering can increase the body's metabolic rate and paradoxically raise the core temperature. Managing the fever should focus on gradual cooling without triggering additional metabolic heat production.
C. Apply blankets during diaphoresis: Applying blankets during diaphoresis, when the child is already sweating, can trap heat and counteract the body's natural efforts to cool down. During diaphoresis, lighter coverings or removing excess clothing is more appropriate to facilitate heat loss.
D. Turn on an oscillating fan: Although using a fan can aid in cooling by promoting air circulation, it can also cause rapid cooling, leading to shivering. Shivering increases metabolic heat production, which may worsen the child's condition during a febrile episode rather than improving it.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Notify the nursing board: Reporting to the nursing board is necessary for ongoing professional accountability but is not the immediate first step. The priority is to ensure the safety of clients by addressing the situation within the facility first.
B. Submit an incident report: An incident report documents the event, but it should be completed after immediate concerns for client safety are addressed. It is not the first action when dealing with an impaired nurse.
C. Email the nurse manager: Emailing the nurse manager may delay the response. Immediate verbal communication with someone in a supervisory role is essential to remove the impaired nurse from client care duties without delay.
D. Inform the charge nurse: Informing the charge nurse immediately is the priority because the charge nurse has the authority to intervene quickly, ensure the impaired nurse is removed from duty, and maintain patient safety. This allows for appropriate administrative steps to follow afterward.
Correct Answer is ["31"]
Explanation
Total volume to be infused: 250 mL of tube feeding.
To be infused over 8 hours.
Calculate the infusion rate in mL per hour.
Infusion rate (mL/hour) = Total volume (mL) / Total infusion time (hours)
= 250 mL / 8 hours
= 31.25
Round to the nearest whole number: 31.
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