Page 960 - Saunders Comprehensive Review For NCLEX-RN

329. Answer: 4

Rationale: After administering ibuprofen, excess clothing and blankets should be
removed. The child can be sponged with tepid water but not cold water, because the
cold water can cause shivering, which increases metabolic requirements above those
already caused by the fever. Aspirin (a salicylate) is not administered to a child with
fever because of the risk of Reye’s syndrome. Fluids should be encouraged to
prevent dehydration, so oral fluids should not be withheld.
Test-Taking Strategy: Focus on the subject, interventions for an elevated
temperature. Remember that cooling measures such as removing excess clothing and
blankets should be done when a child has a fever. Options 1, 2, and 3 are not
interventions for a child with a fever.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pediatrics: Metabolic/Endocrine
Health Problem: Pediatric-Specific: Fever
Priority Concepts: Clinical Judgment; Thermoregulation
Reference: McKinney et al. (2018), p. 831.

330. Answer: 3

Rationale: Indicators that fluid volume deficit is resolving would be capillary refill
less than 2 seconds, specific gravity of 1.003 to 1.030, urine output of at least 1
mL/kg/hr, and adequate tear production. A capillary refill time less than 2 seconds is
the only indicator that the child is improving. Urine output of less than 1 mL/kg/hr, a
specific gravity of 1.035, and no tears would indicate that the deficit is not resolving.
Test-Taking Strategy: Focus on the subject, assessment findings indicating that
fluid volume deficit is resolving. Recall the parameters that indicate adequate
hydration status. The only option that indicates an improving fluid balance is option
3. The other options indicate fluid imbalance.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Pediatrics: Metabolic/Endocrine
Health Problem: Pediatric-Specific: Dehydration
Priority Concepts: Evidence; Fluids and Electrolytes
Reference: McKinney et al. (2018), pp. 892, 894.

331. Answer: 3, 6

Rationale: Hypoglycemia is defined as a blood glucose level less than 70 mg/dL (4
mmol/L). Hypoglycemia occurs as a result of too much insulin, not enough food, or
excessive activity. If possible, the nurse should confirm hypoglycemia with a blood
glucose reading. Glucose is administered orally immediately; rapid-releasing
glucose is followed by a complex carbohydrate and protein, such as a slice of bread
or a peanut butter cracker. An extra snack is given if the next meal is not planned for

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