The nurse is teaching a group of first-time parents who are being discharged with their newborns. One parent asks the nurse what to do if the child has a temperature. After conducting teaching regarding how to care for a child with an elevated temperature, the caregivers make the following statements. Which statement would indicate a need for further teaching?

“A rectal temperature above 102.5 °F (39.1 °C) should be lowered.”

“I don’t plan to give my child medications, but the pediatrician might tell us to give our child acetaminophen every 4 to 6 hours if she has a fever.”

“If my child starts to shiver I will know that what I am doing is working and that her fever will soon come down.”

“Giving extra fluids is the way I have always heard to lower a temperature.”

Answer and Explanation

The Correct Answer is C

Choice A reason: A rectal temperature above 102.5 °F (39.1 °C) warrants intervention to lower fever, aligning with pediatric guidelines. This statement reflects correct understanding of fever management, making it accurate and not indicative of a need for further teaching compared to the shivering misconception in infants.

Choice B reason: Considering acetaminophen per pediatrician guidance shows understanding of safe fever management, even if avoiding medications initially. This reflects appropriate knowledge of consulting professionals, making it correct and not requiring further teaching, unlike the incorrect shivering interpretation needing clarification for parents.

Choice C reason: Shivering during fever indicates the body raising its temperature set point, not fever reduction. This misconception suggests the fever is worsening, not improving, requiring further teaching to clarify fever physiology, aligning with pediatric nursing education, making it the correct choice for additional instruction.

Choice D reason: Giving extra fluids is a standard recommendation to prevent dehydration during fever, reflecting correct knowledge. This statement aligns with fever management guidelines, making it accurate and not needing further teaching, unlike the shivering statement, which misinterprets a critical fever response in children.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A reason: Caregiver holding may comfort but is unreliable for keeping a wiggly 5-year-old still, risking IV dislodgement. A clove-hitch restraint ensures arm stability while allowing some movement, making this less safe and incorrect for maintaining IV security during antibiotic infusion in a resistant child.

Choice B reason: Mummy restraints are excessive for an IV, restricting the whole body and potentially distressing a 5-year-old. A clove-hitch restraint targets the arm, balancing safety and comfort, making this overly restrictive and incorrect for the specific need to secure the IV site in this scenario.

Choice C reason: A clove-hitch restraint secures the arm, preventing IV dislodgement in a resistant 5-year-old while allowing some movement. Loosening every 2 hours ensures circulation, aligning with pediatric nursing safety standards for IV therapy, making it the correct method for ensuring safety during infusion.

Choice D reason: A papoose board is used for short procedures, not prolonged IV infusions, and releasing immediately negates its purpose. A clove-hitch restraint maintains IV security over time, making this impractical and incorrect for ensuring safety during the antibiotic infusion period for the child.

A. “Remove all equipment related to the procedure from the child’s environment.” B. “Handle all contaminated linens in accordance with the facility policies.” C. “Assess to ensure that the side rails are up and the bed is lowered to the floor.” D. “Document the procedure and the response of the child as soon as the procedure is completed.”

Correct Answer is C

Explanation

Choice A reason: Removing equipment reduces clutter but is less urgent than preventing falls, especially post-procedure when a child may be disoriented. Ensuring side rails and a low bed prioritizes safety, making this secondary and incorrect for the most immediate action in pediatric post-procedure care.

Choice B reason: Handling contaminated linens follows infection control but is not the immediate safety concern post-procedure. Preventing falls with side rails and a low bed is critical, making this less urgent and incorrect compared to the priority of ensuring the child’s physical safety after the procedure.

Choice C reason: Assessing side rails up and bed lowered prevents falls, the most immediate safety risk post-procedure when a child may be sedated or unsteady. This aligns with pediatric safety protocols, making it the correct statement for the most urgent action in post-procedure interventions.

Choice D reason: Documentation is essential but not immediate compared to fall prevention, which protects the child post-procedure. Side rails and bed positioning take precedence, making this subsequent and incorrect for the most urgent safety action required after a pediatric procedure in the hospital.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Tess is a 5-year-old client who must receive an IV infusion of antibiotics. She is anxious, resistant, and wiggly. To keep her safe during the time the IV is in place, the nurse would choose which method to restrain her?

Correct Answer is C

Explanation

A nurse is discussing post-procedure interventions with new pediatric nurses. Which statement addresses the most immediate safety action required?

Correct Answer is C

Explanation

The emergency room nurse is caring for a family who lost an adolescent in a violent car accident. Which initial nursing action best helps the family’s grieving process?

The nurse is reviewing a client’s chart and notes that the child is in droplet precautions for pneumonia. What protection would she need to take in caring for the child?

The nurse is attempting to include family in the care of a hospitalized, terminally ill adolescent. Which interventions can be appropriately delegated to family members? (Select all that apply)

The daughter of a divorced couple is hospitalized for injuries received in an automobile accident. The custodial father is at work when the mother arrives extremely agitated and demanding to see her daughter immediately. Which action will be most appropriate for the nurse to take at this time?

The nurse is preparing a presentation depicting the various ways pathogens are spread around. The nurse will illustrate that pathogens passed around via insects is referred to as which mechanism?

The caregiver of a 4-year-old girl who lives in a heavily wooded area calls the clinic nurse to report that the child has a swollen tick on her arm. What would be the best action for the caregiver to follow in removing the tick?

The nursing instructor is illustrating the various types of play. The instructor determines the class is successful when the students correctly choose which example as best representing onlooker play?

The nurse is working with a 12-year-old who is hospitalized with a chronic illness. Which action by the nurse might help the chronically ill preteen thrive while hospitalized?