the nurse is preparing to give acetaminophen tylenol to a child who has a fever what nursing action is appropriate
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Nursing Elites

ATI RN

RN Nursing Care of Children Online Practice 2019 A

1. The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

Correct answer: C

Rationale: Ensuring the dose does not exceed 15 mg/kg is critical to avoid overdose and potential liver damage. Retaking the temperature immediately or using cold compresses is not necessary, and placing a warm blanket could exacerbate the fever.

2. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child?

Correct answer: B

Rationale: Preparation is essential even for a young child, as they need to adjust to the temporary colostomy and understand the changes to their body, which can be confusing and distressing without proper explanation.

3. Using knowledge of child development, what approach is best when preparing a toddler for a procedure?

Correct answer: C

Rationale: Demonstrating on a doll helps the toddler understand what will happen in a non-threatening way, making the procedure less intimidating. Long teaching sessions or avoiding choices can increase anxiety.

4. Parents would suspect hearing loss if their child did not:

Correct answer: D

Rationale: The correct answer is D because babbling is an early indicator of hearing ability in infants. Lack of babbling by 2 months may suggest a potential hearing issue. Choices A, B, and C are incorrect because turning away from a sound, startling with sudden loud noises immediately after birth, and talking at 4 months are not primary indicators of hearing loss in infants.

5. A toddler’s mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse’s response should be based on which premise?

Correct answer: B

Rationale: Radiographic examination is essential to confirm the location of the battery, as it can cause significant damage, particularly if lodged in the esophagus. Immediate surgery may be required depending on its location and the potential for causing harm.

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