The father of a 2-month-old infant calls the advice nurse saying his child has a fever of 38.5°C (101.3°F). The nurse should instruct the father to do which of the following?
Give the infant ibuprofen and then apply cool wet sponges to the infant.
Give the infant acetaminophen now and call back in 2 hours if the fever has not gone down.
Take the infant to the urgent care clinic now.
Put the infant in a cool bath.
The Correct Answer is C
Choice A reason: This statement is incorrect, as ibuprofen is not recommended for infants under 6 months of age due to the risk of kidney damage and bleeding. Cool wet sponges can also cause shivering and increase the body temperature. The nurse should advise the father to avoid these methods and seek medical attention.
Choice B reason: This statement is incorrect, as acetaminophen is not enough to treat a high fever in a 2-month-old infant. The nurse should also inform the father that the normal dose of acetaminophen for infants is 10 to 15 mg/kg every 4 to 6 hours, and that he should not exceed 5 doses in 24 hours. The nurse should urge the father to take the infant to the urgent care clinic as soon as possible.
Choice C reason: This statement is correct, as a fever of 38.5°C (101.3°F) or higher in an infant under 3 months of age is considered a medical emergency and requires immediate evaluation and treatment. The nurse should explain to the father that a high fever in a young infant can indicate a serious infection, such as meningitis, sepsis, or urinary tract infection, and that the infant needs to be seen by a doctor right away.
Choice D reason: This statement is incorrect, as putting the infant in a cool bath can cause hypothermia and shock. The nurse should advise the father to avoid this method and seek medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as Airborne Precautions are not indicated for patients with LIP, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne Precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.
Choice B reason: This statement is incorrect, as LIP is not rarely seen in children with AIDS, but rather one of the most common pulmonary complications of HIV infection in children. LIP affects about 30% to 40% of children with HIV, and is more prevalent in younger children than older children or adults.
Choice C reason: This statement is correct, as LIP is a common AIDS-defining condition in children with HIV. AIDS-defining conditions are illnesses that occur in people with advanced HIV infection and indicate a severe immunosuppression. LIP is a chronic inflammatory disorder of the lungs that causes lymphocytic infiltration of the interstitium and alveoli, leading to respiratory symptoms and impaired gas exchange.
Choice D reason: This statement is incorrect, as antibiotics are not the first-line treatment for LIP, unless there is a bacterial superinfection. Antibiotics do not target the underlying cause of LIP, which is the HIV infection and the associated immune dysfunction. The main treatment for LIP is antiretroviral therapy (ART), which suppresses the viral replication and improves the immune status of the patient. Corticosteroids may also be used to reduce the inflammation and improve the lung function.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Letting the child hear the sounds of an ECG monitor can help reduce anxiety and fear of the unknown. It can also help the child understand what to expect during the surgery and recovery.
Choice B reason: This is not a good choice. Avoiding mentioning postoperative discomfort and interventions can create unrealistic expectations and mistrust. The nurse should provide honest and age-appropriate information about the surgery and the possible complications and pain management.
Choice C reason: This is not a good choice. Explaining that an endotracheal tube will not be needed if the surgery goes well can imply that the surgery might not go well and cause unnecessary worry. The nurse should explain that an endotracheal tube is a common device that helps the child breathe during and after the surgery and that it will be removed as soon as possible.
Choice D reason: This is not a good choice. Unfamiliar equipment should be shown and explained to the child and the family in a simple and reassuring way. This can help them become familiar with the equipment and reduce their fear and anxiety.
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