The young mother of an 8-month-old patient brought her daughter to the clinic after taking the little girl's temperature rectally and obtaining a reading of 100.4 F. The mother was concerned that her daughter might be ill. Which of the following is the best response?
"When taking multiple temperature, the sites should be rotated."
"Because of her age, it is probably a bacterial infection."
"Children usually run lower rather than higher temperatures when ill."
"Rectal temperature readings are higher than temperature obtained orally."
The Correct Answer is D
A. "When taking multiple temperatures, the sites should be rotated.":
This does not address the mother’s concern about the specific temperature reading and its significance.
B. "Because of her age, it is probably a bacterial infection.":
A temp of 100.4°F is low-grade and not diagnostic of bacterial infection, especially in an infant without other symptoms.
C. "Children usually run lower rather than higher temperatures when ill.":
Children often run higher fevers when ill, not lower.
D. "Rectal temperature readings are higher than temperature obtained orally.":
Rectal temperatures are typically 0.5°F to 1°F higher than oral readings. A rectal temp of 100.4°F is considered the threshold for fever in infants but may still be within normal for a well-appearing child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
The findings that require follow-up:
- Redness noted at wound borders, skin surrounding wound is warm to touch
This suggests local infection or inflammation around the wound. - Purulent drainage noted
Purulent (thick, discolored) drainage is a sign of infection and requires prompt follow-up. - Temp 38.9° C (102° F)
This elevated temperature indicates a systemic response, likely due to infection. - WBC 13,500/mm³ (5000 to 10,000 mm³)
This is an elevated WBC count, consistent with infection or inflammation.
Incorrect answers:
- Wound bed is red
A red wound bed in a pressure injury is often a sign of granulation tissue, which is part of the normal healing process, not a concern unless accompanied by other signs of infection. - Hct 37% (37% to 47%)
Hematocrit is within normal limits, and does not indicate concern.
Correct Answer is B
Explanation
A. Elevate the client’s arm above the level of the heart:
This may falsely lower the reading. The arm should be at heart level.
B. Align the artery indicator on the BP cuff with the client’s brachial artery:
Correct alignment ensures accurate readings. Most cuffs have an arrow or line that must align with the brachial artery.
C. Place the BP cuff 5 cm (2 in) above the client’s antecubital space:
The cuff should be placed about 2.5 cm (1 inch) above the antecubital space-not 5 cm.
D. Select a cuff that covers 50% of the client’s upper arm:
The correct cuff should cover at least 80% of the arm’s circumference, not 50%, for accurate readings.
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