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 C

Explanation

A. Weight loss may occur with acute exacerbations but is not a guaranteed effect of prednisone therapy.

B. Prednisone does help reduce inflammation but does not directly relieve abdominal cramping; this statement may reflect a misunderstanding of its action.

C. This statement indicates a clear understanding of the need for gradual tapering of prednisone to prevent withdrawal symptoms and rebound exacerbation.

D. Noticing some medication in the stool is not a common or expected effect of prednisone and may indicate a misunderstanding of how the drug works.

A. Blood pressure B. Respiratory rate C. Skin integrity D. Body weight

Correct Answer is D

Explanation

A. Blood pressure can fluctuate and may not accurately reflect fluid loss in an infant, especially in early stages of dehydration.

B. Respiratory rate may increase with distress but is not a direct indicator of fluid loss.

C. Skin integrity can show signs of dehydration, but it is not as definitive as changes in body weight.

D. Body weight is the most reliable indicator of fluid loss, as it reflects changes in fluid status directly and provides a clear measure for assessing hydration.

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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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Explanation

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