The nurse is caring for a 2 month old child with a fever of 101.76. The child also appears toxic with poor color. Which of the following actions would the nurse expect to implement as a priority?

Replace fluids orally

Administer antibiotics as prescribed

Obtain a specimen for complete blood co

Obtain urinalysis

Answer and Explanation

The Correct Answer is B

A. While fluid replacement is important, in a toxic-appearing child, oral fluids may not be safe or adequate due to potential dehydration and risk of worsening condition.

B. Administering antibiotics is the priority action because the child shows signs of potential serious infection, and timely antibiotic treatment is crucial in young infants who may quickly deteriorate.

C. Obtaining a specimen for a complete blood count is necessary for diagnosing infection but is not as urgent as administering antibiotics.

D. While obtaining a urinalysis may help identify a urinary tract infection, it is not the immediate priority compared to starting antibiotic therapy.

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Correct Answer is C

Explanation

A. Respiratory precautions are necessary for preventing the spread of respiratory infections but are not specifically indicated here.

B. Airborne precautions are required for diseases transmitted through the air (e.g., TB), not relevant in this scenario.

C. Bleeding precautions should be initiated due to the critically low platelet count, as this increases the risk of bleeding complications. Nurses should be vigilant in monitoring for signs of bleeding and minimizing invasive procedures.

D. Contact precautions are important for preventing the spread of infections, but in this case, the primary concern is bleeding due to low platelet counts.

A. Bagel with cream cheese and lox B. Vanilla milkshake made with pasteurized milk C. Ham and cheese sandwich D. Sushi

Correct Answer is B

Explanation

A. Bagels with cream cheese and lox are not recommended as lox may carry a risk of contamination.

B. A vanilla milkshake made with pasteurized milk is safe for a neutropenic diet as pasteurization kills harmful bacteria.

C. Ham and cheese sandwiches may not be safe unless the ham is fully cooked, as deli meats can harbor bacteria.

D. Sushi is not appropriate for a neutropenic diet due to the risk of raw fish and potential bacteria.

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The nurse is caring for a 2 month old child with a fever of 101.76. The child also appears toxic with poor color. Which of the following actions would the nurse expect to implement as a priority?

Nursing Test Bank

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