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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Show acceptance of the client's current feelings: Accepting the client’s emotional response without judgment builds trust and provides emotional support, which is critical when coping with a new diagnosis of advanced cancer.
B. Share a similar personal experience: Sharing personal experiences shifts the focus away from the client’s feelings and can be perceived as minimizing their unique emotional response. It is more therapeutic to focus entirely on the client’s experience.
C. Document the behavior in the client's record: Accurate documentation of the client's emotional state ensures continuity of care and alerts other healthcare providers to the client's need for emotional support and potential interventions.
D. Ask the palliative care nurse to see the client: Involving a palliative care specialist provides expert emotional, spiritual, and symptom management support, which is appropriate for a client newly diagnosed with stage IV cancer.
E. Allow the client a time to continue crying: Allowing the client to cry acknowledges their need to express grief and emotion. It helps the client begin processing the overwhelming news and supports healthy emotional expression.
Correct Answer is B
Explanation
A. Extend thumb at a right angle during gloving: Positioning the thumb may help with glove placement but does not directly maintain surgical asepsis. The focus of aseptic technique is keeping gloves sterile, not thumb positioning during the process.
B. Keep gloved hands in sight above waist level: Keeping hands in sight and above waist level is essential for maintaining surgical asepsis. Anything below waist level is considered contaminated, and visibility ensures that sterility is not compromised during procedures.
C. Touch cuff fold only while applying second glove: Touching the cuff is appropriate when donning the second glove, but maintaining hand position above waist level is a broader and ongoing requirement to uphold sterile technique throughout the procedure.
D. Apply a mask once both hands are gloved: Masks should already be in place before starting the sterile gloving procedure. Waiting to apply a mask after donning sterile gloves risks contaminating the gloves and breaking sterile technique.
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