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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While clear chicken broth can provide some hydration, it does not contain the necessary electrolytes to replace losses effectively.
B. Initiating oral rehydration therapy is critical for managing dehydration due to diarrhea and is the best approach for a child in this situation.
C. Starting a hypertonic solution is inappropriate and could lead to further dehydration or electrolyte imbalances.
D. Keeping the child NPO is not necessary; it is more important to maintain hydration and possibly offer oral rehydration solutions.
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.
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