A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?
Give 500 mg acetaminophen PO every 2 hr.
Administer a 300-mg aspirin suppository.
Place the child in an ice bath.
Lower the temperature of the room.
The Correct Answer is D
Choice A reason:
This is a high dose for a 2 year old child.
Choice B reason:
Aspirin is contraindicated for children with viral infections due to the risk of Reye's syndrome. It should not be administered.
Choice C reason:
Placing the child in an ice bath is an overly aggressive intervention and can lead to hypothermia. It is not recommended.
Choice D reason:
Lowering the temperature of the room is important in reducing external temperature to help cool the baby.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Taping the wire to the palm of the hand can be uncomfortable for the child and may interfere with blood flow.
Choice B reason:
Warming the skin prior to probe placement is not a standard practice for pulse oximetry monitoring.
Choice C reason:
Applying the sensor to the index fingernail is not a recommended site for pulse oximetry monitoring in children.
Choice D reason:
Repositioning the probe every 2 hours helps to prevent skin breakdown and ensures accurate readings over time. This is a standard practice in pulse oximetry monitoring.
Correct Answer is D
Explanation
Choice A reason:
While an oatmeal bath can provide relief from itching, it is not the first step in treating poison ivy exposure. The immediate priority is to remove the plant oils from the skin.
Choice B reason:
Administering an oral corticosteroid may be indicated for severe cases of poison ivy, but it is not the initial step. Removing the plant oils from the skin is the first priority.
Choice C reason:
Applying calamine lotion can help soothe itching, but it is not the first action to take. The priority is to remove any remaining plant oils from the skin.
Choice D reason:
The first action the nurse should take is to remove any remaining plant oils from the skin by flushing the affected area with cold, running water. This helps to prevent further absorption of the irritant.
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