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A nurse is caring for a toddler who has a respiratory illness and a temperature of 39.3° C (102.7° F). Which of the following actions should the nurse take to reduce the toddler's temperature?
- A. Give the toddler a tepid bath.
- B. Administer an aspirin suppository.
- C. Remove the toddler's extra clothing.
- D. Apply a cooling blanket.
Correct Answer: C
Rationale: Removing extra clothing allows heat loss safely. Tepid baths risk shivering, aspirin risks Reye's syndrome, and cooling blankets are for severe cases.
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A nurse is reinforcing teaching with an adolescent client who has oral candidiasis and a new prescription for clotrimazole troche. Which of the following instructions should the nurse include in the teaching?
- A. Place the medication in the refrigerator after each use.
- B. Be sure to let the troche dissolve in your mouth for 15 minutes.
- C. Crush the troche before mixing it with applesauce.
- D. Stop the medication if white patches appear in your mouth.
Correct Answer: B
Rationale: Dissolving the troche slowly maximizes effectiveness. Refrigeration isn't needed, crushing alters delivery, and white patches indicate ongoing infection, not a reason to stop.
A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority?
- A. Skin turgor
- B. Potassium level
- C. Capillary refill
- D. Heart rate
Correct Answer: D
Rationale: The elevated heart rate (tachycardia) at 182/min indicates increased cardiac workload, likely due to dehydration from gastroenteritis, requiring immediate attention. While skin turgor, potassium levels, and capillary refill are important, tachycardia is the priority to stabilize the infant.
A nurse is assisting with the care of an infant who requires emergency surgery and whose parent is an emancipated adolescent. Which of the following people can sign the informed consent form for the procedure?
- A. The parent of the adolescent parent
- B. The adolescent parent
- C. The infant's provider
- D. The adult sibling of the adolescent parent
Correct Answer: B
Rationale: An emancipated adolescent parent has legal authority to consent for their child's procedure. Others lack this authority unless legally designated.
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take?
- A. Use an automated lancet device to puncture the heel.
- B. Apply limb restraints to the infant.
- C. Puncture the heel at the inner aspect of the heel.
- D. Cleanse the area with povidone iodine.
Correct Answer: A
Rationale: An automated lancet device ensures a controlled puncture, minimizing discomfort. Restraints are unnecessary, the inner heel is not the correct site, and povidone iodine is not typically used for heel sticks.
A nurse is caring for an infant who has a cleft palate and is having trouble bottle feeding. Which of the following actions should the nurse take?
- A. Select a bottle with a one-way flow valve.
- B. Choose a bottle with a narrow nipple.
- C. Burp the infant every 90 ml (3 oz).
- D. Use the football hold when feeding the child.
Correct Answer: A
Rationale: A one-way flow valve bottle controls milk flow, aiding infants with cleft palate. Narrow nipples, frequent burping, or football hold are less specific to feeding challenges.