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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason:

A weight loss of 0.25 kg (0.55 lb) may be within the range of normal fluctuation for an infant and may not necessarily warrant immediate reporting. However, it should be monitored closely.

Choice B reason:

Vomiting twice in 4 hours after receiving digoxin is a concerning finding. Digoxin has a narrow therapeutic range, and vomiting can lead to potential overdose. This should be reported to the provider for further evaluation.

Choice C reason:

A respiratory rate of 30/min may indicate increased work of breathing, which is a concern in an infant with heart failure. However, it is not specific to digoxin administration and may require

intervention but not immediate reporting.

Choice D reason:

A heart rate of 130/min is within the range of normal for an infant, especially one with heart failure. This finding is not specific to digoxin administration and may not warrant immediate reporting.

A. "Obtain a pneumococcal immunization for your child." B. "Avoid allowing your child to participate in school sports." C. "Have your child inhale deeply and quickly when using the peak flow meter." D. "Use salmeterol to manage your child's acute exacerbations."

Correct Answer is A

Explanation

Choice A reason:

Obtaining a pneumococcal immunization is an important preventive measure for children with asthma, as respiratory infections can exacerbate their condition.

Choice B reason:

Encouraging physical activity is important for children with asthma. While some precautions may be necessary, avoiding participation in school sports altogether is not recommended.

Choice C reason:

Having the child inhale deeply and quickly when using the peak flow meter is not the recommended technique. The child should take a deep breath and exhale forcefully to obtain an accurate reading.

Choice D reason:

Salmeterol is a long-acting beta-agonist (LABA) used for maintenance therapy, not for managing acute exacerbations. It should be used in combination with an inhaled corticosteroid for optimal asthma control.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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