A nurse is assessing a child with a fever of 103°F (39.4°C). The nurse should prioritize which of the following?

Correct Answer: C

Rationale: The correct answer is C) Assessing for other signs of infection. When a child presents with a fever, it is crucial to assess for other signs of infection to determine the underlying cause. Fever can be a symptom of various conditions, including infections. By assessing for other signs such as cough, runny nose, rash, or pain, the nurse can gather more information to guide further interventions and treatment. Option A) Administering acetaminophen to reduce fever is important to provide comfort to the child and help reduce fever-related symptoms. However, it is not the priority in this situation. The underlying cause of the fever needs to be identified first. Option B) Encouraging the child to drink fluids is a good practice to prevent dehydration, but it is not the priority when assessing a child with a fever. Dehydration can be a concern but should come after assessing for signs of infection. Option D) Monitoring the fever every hour is important in the ongoing care of the child, but initially, assessing for other signs of infection takes precedence to determine the appropriate course of action. In an educational context, prioritizing nursing interventions based on assessment findings is a fundamental skill in pediatric nursing. Understanding the hierarchy of needs and immediate concerns helps nurses provide efficient and effective care to pediatric patients. By focusing on assessing for signs of infection first, nurses can address the root cause of the fever and tailor their care accordingly.

Correct Answer: C

Rationale: The correct answer is C) Clear mucus from the lungs. Rationale: Chest physiotherapy is a crucial part of the treatment plan for children with cystic fibrosis. This therapy involves various techniques such as percussion, vibration, and postural drainage to help loosen and clear the thick, sticky mucus that builds up in the lungs of individuals with cystic fibrosis. By clearing the mucus from the lungs, chest physiotherapy helps improve ventilation, reduce the risk of respiratory infections, and enhance overall lung function in these children. Option A) Improve the child's ability to breathe deeply is incorrect because while chest physiotherapy can indirectly help improve breathing by clearing the airways, its primary goal is to clear mucus rather than focusing on deep breathing techniques. Option B) Increase lung compliance is not the primary purpose of chest physiotherapy in cystic fibrosis. Lung compliance refers to the ability of the lungs to expand and contract, and while chest physiotherapy can help with lung function, its main aim in cystic fibrosis is mucus clearance. Option D) Strengthen the child's respiratory muscles is also not the main goal of chest physiotherapy in cystic fibrosis. While chest physiotherapy may provide some benefits to respiratory muscle strength, its primary focus is on clearing mucus from the lungs to improve respiratory function and prevent complications. Educational context: Understanding the rationale behind the use of chest physiotherapy in children with cystic fibrosis is essential for nurses and healthcare providers involved in the care of these patients. By educating parents about the importance of daily chest physiotherapy and its role in clearing mucus from the lungs, nurses can empower them to take an active role in managing their child's condition and promoting better respiratory health outcomes.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Increasing the child's fluid intake. This intervention is a priority because it helps to promote urinary tract health by increasing urine output, which can help flush out bacteria and prevent the recurrence of UTIs. By increasing fluid intake, the child will have more frequent urination, reducing the chances of bacteria multiplying in the urinary tract. Option A) Encouraging regular urination is important, but increasing fluid intake takes precedence as it directly impacts the urinary tract's ability to flush out bacteria. Regular urination is a supportive measure to maintain urinary tract health. Option C) Administering antibiotics as prescribed is necessary to treat existing UTIs, but it does not address the prevention aspect of recurring infections. Antibiotics treat the current infection but do not prevent future ones. Option D) Educating the child on proper hygiene practices is essential for preventing UTIs, but in this case, increasing fluid intake is more crucial as it directly affects the physiological process of flushing out bacteria from the urinary tract. Educationally, understanding the importance of adequate fluid intake in preventing UTIs is crucial for pediatric nurses. Teaching parents and children about the role of hydration in urinary tract health can empower them to take proactive steps in preventing infections. Nurses play a key role in educating families about simple yet effective strategies to promote children's urinary health, ultimately improving their overall well-being.

Correct Answer: A

Rationale: The correct answer is A) Respiratory rate and oxygen saturation. Monitoring respiratory rate and oxygen saturation during an asthma attack is crucial as it provides essential information about the child's respiratory status and oxygenation levels. In asthma, the airways become inflamed and narrowed, leading to difficulty breathing and decreased oxygen levels. By monitoring respiratory rate, the nurse can assess the child's breathing pattern and identify any signs of respiratory distress. Oxygen saturation levels indicate how well the child's lungs are oxygenating the blood, which is vital for determining the severity of the asthma attack and the effectiveness of interventions. Option B) Body temperature and blood pressure are not typically the primary parameters to monitor during an asthma attack. Asthma is primarily a respiratory condition, so focusing on respiratory parameters is more relevant. Option C) Heart rate and reflexes, while important in assessing overall health, may not provide specific information related to respiratory distress in an asthma attack. Option D) Muscle strength and alertness are not directly related to monitoring respiratory status during an asthma attack. While changes in muscle strength or alertness could indicate distress, they are not the primary indicators of respiratory compromise in asthma. For nursing students preparing for the NCLEX, understanding the importance of monitoring respiratory rate and oxygen saturation in pediatric patients with asthma is essential for providing safe and effective care. By emphasizing these key parameters, nurses can promptly identify worsening respiratory status, intervene appropriately, and prevent complications associated with asthma exacerbations.

Correct Answer: B

Rationale: The correct answer to the question is B) Hand washing. This is because proper hand hygiene is the single most effective way to prevent the spread of communicable diseases. By washing hands regularly with soap and water or using hand sanitizer, the transmission of pathogens from person to person can be significantly reduced. Option A) Immunizations as secondary prevention are important in preventing specific diseases, but they are not the most important method for preventing the spread of communicable diseases in general. Immunizations protect individuals from contracting specific diseases but do not directly prevent the spread of all communicable diseases. Option C) Isolation from infectious agents is a control measure used in healthcare settings to prevent the spread of specific infections, but it is not a practical or feasible method for preventing the spread of all communicable diseases in the community at large. Option D) The use of appropriate broad-spectrum antibiotics is a treatment method for bacterial infections and should not be used as a primary prevention method for the spread of communicable diseases. Inappropriate use of antibiotics can lead to antibiotic resistance and other negative consequences. In an educational context, it is essential to emphasize the importance of proper hand hygiene as a fundamental practice in preventing the spread of diseases, especially in pediatric populations who may be more vulnerable to infections. Teaching children and their caregivers about the correct way to wash hands and encouraging regular handwashing can have a significant impact on reducing the incidence of communicable diseases in the community.