A 3-year-old patient is admitted to the pediatric unit with a fever of 103 ° F. Which actions will the nurse implement? (Select all that apply.)
a. Assess rectal temperature every 4 hours.
b. Administer Acetaminophen as ordered.
c. Assess skin turgor.
d. Restrict fluids.
e. Assess level of consciousness.
ANS: B, C, E
When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the child to cuddling, alertness, hydration, sociability, and quality of cry. A quiet, lethargic child who does not respond readily to the environment may be acutely ill. Because dehydration is a common problem in infants and children, skin turgor should be assessed. Antipyretics also provide comfort and may aid in enabling the child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for pediatric patients.
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