The nurse is monitoring for signs and symptoms of dehydration in a 1 year old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?
Orally
Tympanic
Rectal
Axillary
The Correct Answer is C
A. Orally: Oral temperature measurement is generally not suitable for a 1-year-old because they are often not able to cooperate, but it is not contraindicated for the child.
B. Tympanic: Tympanic (ear) temperature measurement is acceptable in children over 3 months old and is non-invasive.
C. Rectal: Rectal temperature should be avoided in infants and toddlers with diarrhea due to the risk of rectal trauma and infection. Diarrhea may also cause irritation to the rectal area, increasing the risk of injury.
D. Axillary: Axillary (underarm) temperature measurement is safe and commonly used in children, particularly for non-invasive monitoring.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
A. Air or Barium enema: This is both diagnostic and therapeutic. The enema can reduce the intussusception by relieving the telescoping of the bowel.
B. IV fluids until spasm subsides: While IV fluids are used to manage dehydration, they do not resolve intussusception.
C. Immediate surgery: Surgery is reserved for cases where enemas are unsuccessful or complications like perforation occur.
D. Gastric gavage: This is not related to treating intussusception and does not address the underlying issue.
Correct Answer is D
Explanation
A. Place the infant supine in a crib prior to administration: The infant should be in an upright position to prevent choking or aspiration.
B. Mix the medication with 10 mL of formula: Medications should not be mixed with a large volume of formula to ensure the infant consumes the full dose.
C. Measure the elixir in a medicine cup before transferring to a syringe: The syringe should be used directly to avoid dosing errors.
D. Position the syringe to the side of the infant's tongue: This technique ensures the medication is delivered effectively and minimizes the risk of choking.
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