The nurse is caring for a 2 month old child with a fever of 101.76. The child also appears toxic with poor color. Which of the following actions would the nurse expect to implement as a priority?

Replace fluids orally

Administer antibiotics as prescribed

Obtain a specimen for complete blood co

Obtain urinalysis

Answer and Explanation

The Correct Answer is B

A. While fluid replacement is important, in a toxic-appearing child, oral fluids may not be safe or adequate due to potential dehydration and risk of worsening condition.

B. Administering antibiotics is the priority action because the child shows signs of potential serious infection, and timely antibiotic treatment is crucial in young infants who may quickly deteriorate.

C. Obtaining a specimen for a complete blood count is necessary for diagnosing infection but is not as urgent as administering antibiotics.

D. While obtaining a urinalysis may help identify a urinary tract infection, it is not the immediate priority compared to starting antibiotic therapy.

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Correct Answer is B

Explanation

A. Acetaminophen can be given every 4 to 6 hours, but every 2 hours is too frequent and indicates a need for further teaching.

B. The maximum daily dose for a child should be based on their weight and typically should not exceed 75 mg/kg/day; stating 4000 mg is too high for a child, indicating a misunderstanding of dosing.

C. Administering acetaminophen rectally is appropriate if the child cannot take it orally, particularly during vomiting episodes.

D. Notifying the provider about jaundice is critical, as it may indicate liver dysfunction, which is important when using acetaminophen.

A. Weighing on the same scale each day B. Testing the urine for glucose levels regularly C. Increasing fluid intake by 50 ml per hour D. Ambulating 3 to 4 times a day E. Complete the course of prescribed antibiotics

Correct Answer is A

Explanation

A. Weighing the child daily on the same scale is critical for monitoring fluid retention and managing edema, which are primary concerns in nephrotic syndrome.

B. Testing urine for glucose levels is not a routine part of nephrotic syndrome management, as glucose levels are not typically affected by this condition.

C. Increasing fluid intake is not advisable in nephrotic syndrome if there is significant edema; fluid management must be tailored to the child's condition.

D. While ambulation is beneficial, it is not as critical as daily weight monitoring in managing nephrotic syndrome.

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The nurse is caring for a 2 month old child with a fever of 101.76. The child also appears toxic with poor color. Which of the following actions would the nurse expect to implement as a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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