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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Healthcare provider notified, client refuses to have blood glucose taken: While this option indicates that the healthcare provider was informed and that the client refused, it does not fully capture the client’s expressed reason for refusal. Complete and precise documentation includes the client’s statement in their own words.
B. Blood glucose not obtained because client no longer wants to have finger stick: This phrasing is too casual and lacks the specificity needed for legal and clinical documentation. It does not reflect the client’s exact words or demonstrate that the healthcare provider was informed about the situation.
C. Refused finger stick and states, "My finger is sore and test useless." Healthcare provider notified: This option best meets documentation standards by including the client's direct quote, ensuring accurate and objective recording of the refusal, and noting that the healthcare provider was informed. It provides a clear, detailed account suitable for medical and legal purposes.
D. Healthcare provider notified that client is uncooperative and irritable, glucose level not assessed: Describing the client as uncooperative and irritable is subjective and could be considered judgmental. Proper documentation should remain objective, focusing on the client’s stated concerns rather than labeling their behavior.

A. An older adult with a blood pressure of 140/88 mm Hg. B. An adult who has a respiratory rate of 18 breaths/minute. C. A preschooler with an oral temperature of 98.2° F (36.7° C). D. A one-month-old infant with a heart rate of 80 beats/minute.

Correct Answer is D

Explanation

A. An older adult with a blood pressure of 140/88 mm Hg: This blood pressure is slightly elevated but is common in older adults. It does not require immediate intervention unless accompanied by other concerning symptoms like chest pain or altered mental status.
B. An adult who has a respiratory rate of 18 breaths/minute: A respiratory rate of 18 is within the normal adult range (12–20 breaths/minute) and does not suggest respiratory distress or require urgent intervention.
C. A preschooler with an oral temperature of 98.2° F (36.7° C): This temperature is normal for a preschooler, and no immediate action is needed as it falls well within the expected range for healthy children.
D. A one-month-old infant with a heart rate of 80 beats/minute: A normal heart rate for a one-month-old infant ranges from about 100–160 beats per minute. A heart rate of 80 is dangerously low (bradycardia) for an infant and warrants immediate intervention to assess for respiratory or cardiac compromise.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The unlicensed assistive personnel (UAP) working in a small community hospital obtains 0800 vital sign measurements of clients on the unit. In reviewing these vital signs, which measurement warrants immediate intervention by the practical nurse?

Correct Answer is D

Explanation

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