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 ["C","D","E"]
Explanation
Choice A reason:
Tinnitus - Tinnitus (ringing in the ears) is not typically associated with bacterial meningitis. The focus is on central nervous system symptoms and signs of meningeal irritation.
Choice B reason:
Negative Kernig sign - This is a classic sign of meningeal irritation. In bacterial meningitis, the Kernig sign will be positive, indicating resistance and pain upon extension of the knee after flexing the hip.
Choice C reason:
Vomiting - Nausea and vomiting are common symptoms of bacterial meningitis. They are caused by increased intracranial pressure and meningeal irritation.
Choice D reason:
Headache - Headache is a common symptom of bacterial meningitis, often severe and accompanied by other signs of meningeal irritation.
Choice E reason:
Seizures - Seizures can occur in bacterial meningitis due to the inflammation and irritation of the brain.
Correct Answer is B
Explanation
Choice A reason:
A blood glucose level of 220 mg/dL is elevated and should be addressed, but it may not be an immediate priority compared to the presence of Kussmaul respirations.
Choice B reason.
Correct. Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), a severe complication of diabetes. This requires immediate attention and intervention.
Choice C reason:
Vomiting is a concerning symptom, but it may not be as immediately life-threatening as Kussmaul respirations.
Choice D reason:
Frequent urination is a common symptom of diabetes, but it may not require immediate intervention unless it is accompanied by other severe symptoms.
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