When caring for an infant with an upper respiratory tract infection and elevated temperature, which appropriate nursing intervention should the nurse implement?
Give tepid water baths to reduce fever.
Encourage food intake to maintain caloric needs.
Have child wear heavy clothing to prevent chilling.
Give small amounts of favorite fluids frequently to prevent dehydration.
The Correct Answer is D
Give small amounts of favorite fluids frequently to prevent dehydration.
Dehydration is a common complication of upper respiratory tract infections in infants, especially if they have a fever. Giving small amounts of fluids frequently can help maintain hydration and electrolyte balance.
Some additional information about the other choices are:
Choice A is wrong because tepid water baths are not recommended for fever reduction. They can cause shivering, which increases heat production and can raise the
temperature further. Instead, antipyretics such as acetaminophen or ibuprofen can be given as prescribed.
Choice B is wrong because food intake may be decreased due to poor appetite, difficulty breathing, or sore throat. Forcing food intake can cause vomiting or aspiration. Fluid intake is more important than caloric intake during an acute infection.
Choice C is wrong because heavy clothing can increase heat retention and discomfort. The infant should be dressed in light clothing and the room temperature should be comfortable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The patient is showing signs of magnesium toxicity, such as respiratory depression, hyporeflexia, and flushing.
Magnesium sulfate is a high-alert medication that can cause serious adverse effects if not monitored closely.
The nurse should stop the infusion immediately and notify the provider.
Choice A is wrong because calling for a stat magnesium sulfate level will not address the immediate problem of toxicity.
The nurse should act quickly to prevent further complications.
Choice B is wrong because administering oxygen will not reverse the effects of magnesium toxicity.
Oxygen may be helpful for respiratory distress, but it will not correct the underlying cause.
Choice D is wrong because hydralazine is an antihypertensive medication that lowers blood pressure.
The patient’s blood pressure is already within the normal range for a pregnant woman with preeclampsia (140-160/90-110 mm Hg).
Hydralazine may cause hypotension and fetal distress.
Correct Answer is E
Explanation
The presence or absence of anxiety is a noninvasive assessment that the RN would perform to evaluate the patient’s psychological status and possible signs of hypovolemic shock.
Anxiety can indicate reduced cerebral perfusion due to blood loss and low blood pressure.
Choice A is wrong because pulse oximetry is a noninvasive assessment that the RN would perform to measure the oxygen saturation of the patient’s blood, not the circulatory status.
Choice B is wrong because heart sounds are a noninvasive assessment that the RN would perform to auscultate the cardiac rhythm and rate of the patient, not the circulatory status.
Choice C is wrong because arterial pulses are a noninvasive assessment that the RN would perform to palpate the strength and quality of the patient’s peripheral pulses, not the circulatory status.
Choice D is wrong because skin color, temperature, and turgor are noninvasive assessments that the RN would perform to observe the skin integrity and hydration of the patient, not the circulatory status.
Normal ranges for pulse oximetry are 95% to 100%, for heart rate are 60 to 100 beats per minute, and for blood pressure are 120/80 mmHg.
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