When caring for an infant with an upper respiratory tract infection and elevated temperature, which appropriate nursing intervention should the nurse implement?
Give tepid water baths to reduce fever.
Encourage food intake to maintain caloric needs.
Have child wear heavy clothing to prevent chilling.
Give small amounts of favorite fluids frequently to prevent dehydration.
The Correct Answer is D
Give small amounts of favorite fluids frequently to prevent dehydration.
Dehydration is a common complication of upper respiratory tract infections in infants, especially if they have a fever. Giving small amounts of fluids frequently can help maintain hydration and electrolyte balance.
Some additional information about the other choices are:
Choice A is wrong because tepid water baths are not recommended for fever reduction. They can cause shivering, which increases heat production and can raise the
temperature further. Instead, antipyretics such as acetaminophen or ibuprofen can be given as prescribed.
Choice B is wrong because food intake may be decreased due to poor appetite, difficulty breathing, or sore throat. Forcing food intake can cause vomiting or aspiration. Fluid intake is more important than caloric intake during an acute infection.
Choice C is wrong because heavy clothing can increase heat retention and discomfort. The infant should be dressed in light clothing and the room temperature should be comfortable.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Chronic otitis media with effusion (OME) is a condition where fluid accumulates in the middle ear without signs of infection.
This can cause hearing loss, speech delay, and balance problems. The child may complain of a feeling of fullness or pressure in the ear.
Choice A is wrong because a fever as high as 40° C (104° F) is a sign of acute otitis media, which is an infection of the middle ear with inflammation and pus formation.
Choice B is wrong because severe pain in the ear is also a sign of acute otitis media, not chronic otitis media with effusion.
Choice C is wrong because nausea and vomiting are not typical symptoms of chronic otitis media with effusion. They may be associated with other conditions such as gastroenteritis or vestibular disorders.
Correct Answer is D
Explanation
This test measures the amount of chloride in the sweat, which is abnormally high in people with cystic fibrosis (CF). CF is an inherited disorder that affects the cells that produce mucus, sweat, and digestive juices.
Choice A is wrong because bronchoscopy is a procedure that allows the doctor to examine the airways and lungs, but it is not essential for diagnosing CF.
Choice B is wrong because serum calcium is a blood test that measures the level of calcium in the blood, which is not related to CF.
Choice C is wrong because urine creatinine is a test that measures the amount of creatinine in the urine, which reflects the kidney function, but it is not relevant to CF.
Normal ranges for sweat chloride test are:
- Less than 40 millimoles per liter (mmol/L) for children and adults
- Less than 30 mmol/L for infants younger than 6 months
A sweat chloride level of more than 60 mmol/L is considered positive for CF.
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