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 ["A","B","C","D"]
Explanation
These are all positive signs of pregnancy, which are definitive and can only be explained by the presence of a fetus.A positive sign of pregnancy is fetal movement palpated by the nurse-midwife.
Choice E is wrong because a positive hCG test is a probable sign of pregnancy, not a positive one.A probable sign of pregnancy is strongly suggestive of pregnancy but could have other causes.A positive hCG test could be caused by medications, tumors, or other conditions that affect the level of hCG in the blood or urine.
Some other probable signs of pregnancy are uterine enlargement, Hegar’s sign (softening of the lower uterine segment), Goodell’s sign (softening of the cervix), Chadwick’s sign (bluish discoloration of the cervix), ballottement (rebound of the fetus when tapped by the examiner’s finger), Braxton Hicks contractions (painless, irregular uterine contractions), and positive pregnancy test.
Some other positive signs of pregnancy are identification of fetal heartbeat, visualization of the fetus by ultrasound or x-ray, and verification of fetal movement by an experienced clinician.
Correct Answer is A
Explanation
A brilliant, uniform red reflex in both eyes is a sign of a healthy retina and optic nerve. The red reflex is the reflection of light from the retina that varies in color depending on the patient’s skin tone. It can be seen by holding the ophthalmoscope directly in front of your eye and asking the patient to focus on a point in the distance.
Choice B is wrong because an abnormal finding would be an absent or asymmetric red reflex, which could indicate cataracts, retinal detachment, or other eye diseases.
Choice C is wrong because a possible visual defect would not affect the red reflex, but rather the visual acuity or field of vision of the patient.
A vision screening would involve testing the patient’s ability to read letters or numbers at different distances.
Choice D is wrong because small hemorrhages would not cause a brilliant, uniform red reflex, but rather dark spots or blotches on the retina that can be seen with the ophthalmoscope.
Hemorrhages can be caused by diabetes, hypertension, or trauma.
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