A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever.

Which of the following responses should the nurse make?

"You should follow the label directions based on your child's weight."

"You should avoid administering aspirin to your child."

"Your child will require an antibiotic if she develops a fever."

"Your child can have two baby aspirins every 4 hours."

Answer and Explanation

The Correct Answer is B

Explanation:

The nurse should respond by recommending that the parent avoids administering aspirin to the child. The use of aspirin in children, especially those under the age of 18, is associated with the risk of developing Reye's syndrome, a rare but serious condition that aﬀects the liver and brain. It is important to educate parents about the potential risks of using aspirin in children, particularly when they have a fever. Instead, the nurse should advise the parent to use appropriate dosages of acetaminophen or ibuprofen based on the child's weight and follow the label directions for administration.

Option a suggests following the label directions based on the child's weight, which may not specifically address the use of aspirin in children and the risk of Reye's syndrome. Option c, stating that the child will require an antibiotic if she develops a fever, is incorrect because antibiotics are not indicated for all fevers and should only be prescribed if there is an underlying bacterial infection. Option d, suggesting that the child can have two baby aspirins every 4 hours, is incorrect and contradicts the recommendation to avoid administering aspirin to the child.

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Correct Answer is B

Explanation

b. "You can use an adhesive remover when changing the colostomy skin barrier."

The nurse should inform the client that they can use an adhesive remover when changing the colostomy skin barrier. Adhesive removers are helpful in gently removing the adhesive residue left behind by the previous ostomy appliance. This can make the process of changing the colostomy skin barrier more comfortable for the client and help prevent skin irritation or damage.

Explanation for the other options:

a. "You should scrub the skin around the colostomy when cleaning." Scrubbing the skin around the colostomy can be harsh and may cause skin irritation or damage. It is recommended to clean the peristomal skin gently using mild soap and water, followed by thorough drying.

c. "You will need a device to suction stool from the colostomy bag." Suctioning stool from the colostomy bag is not a routine procedure for colostomy care. Colostomy bags are designed to collect stool, and emptying the bag as needed is the appropriate method of management.

d. "You should empty the colostomy bag when it is three-fourths full." The timing of emptying the colostomy bag may vary for each individual. It is generally recommended to empty the colostomy bag when it is one-third to one-half full to prevent leakage or discomfort. The client should be educated on monitoring the bag and emptying it as necessary based on their own output and comfort level.

A. Puncture the heel to a depth of 4 mm to obtain the specimen. B. Withhold feeding prior to collecting the specimen. C. Apply a heat pack 5 to 10 minutes prior to the procedure. D. Elevate the newborn's foot for 15 minutes following the procedure.

Correct Answer is C

Explanation

The nurse should apply a heat pack 5 to 10 minutes prior to the procedure when planning to obtain blood from a newborn via a heel stick. This helps to increase blood ﬂow to the area and makes it easier to obtain the specimen.

a) Puncturing the heel to a depth of 4 mm is too deep and can cause injury to the newborn. The recommended depth for a heel stick is 2.4 mm or less.

b) Withholding feeding prior to collecting the specimen is not necessary.

d) Elevating the newborn's foot for 15 minutes following the procedure is not necessary.

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A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is planning to obtain blood from a newborn via a heel stick. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever.

Which of the following responses should the nurse make?