Nursing Elites

1. A 12-month-old child presents to the clinic for a well visit after missing several appointments. The child began her immunization schedule but has missed several follow-up appointments and doses of immunizations. What is the most appropriate nursing intervention?

• A. Administer initial immunizations from the beginning of the schedule.
• B. The child cannot receive missed immunizations if the schedule is not followed and will not be vaccinated.
• C. The child should only receive the missed doses of immunizations based on the catch-up schedule.
• D. The child should receive double-strength immunizations at this well visit.

Correct answer: C

Rationale: Children who began primary immunization at the recommended age but fail to receive all the doses do not need to begin the series again but should receive only the missed doses. The child may receive missed vaccinations on a catch-up schedule per CDC guidelines.

2. What is the recommended position for a child after a tonsillectomy?

• A. Supine
• B. Prone
• C. Side-lying
• D. Fowler's position

Correct answer: C

Rationale: The correct answer is C: Side-lying. The side-lying position is recommended after a tonsillectomy to facilitate drainage of secretions and reduce the risk of aspiration. This position helps prevent blood from pooling in the back of the throat, decreasing the chance of bleeding postoperatively. Supine (lying face up), while commonly used in other situations, may not be ideal immediately after a tonsillectomy due to the risk of airway obstruction from blood clots. Prone (lying face down) is not recommended as it can hinder breathing and increase the risk of complications. Fowler's position (semi-sitting) is also not typically used after a tonsillectomy because it may cause discomfort and hinder proper drainage.

3. The nurse is performing an oral examination on a preschool child. Which strategies should the nurse use to encourage the child to open the mouth for the examination? (Select all that apply.)

• A. Lightly brush the palate with a cotton swab
• B. Perform the examination in front of a mirror
• C. Let the child examine someone else's mouth first
• D. All of the above

Correct answer: D

Rationale: Using a cotton swab, allowing the child to observe, and demonstrating on someone else are effective ways to encourage a preschooler to open their mouth for examination.

4. Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?

• A. Apply a urine collection bag to the perineal area.
• B. Tape a small medicine cup inside of the diaper.
• C. Aspirate urine from cotton balls inside the diaper with a syringe without a needle.
• D. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.

Correct answer: C

Rationale: Aspirating urine from cotton balls inside the diaper is a minimally invasive method and effective for collecting small amounts of urine. Using a collection bag can be more cumbersome, and other methods are not as effective for this age.

5. Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?

• A. Hepatitis B
• B. Polio
• C. Measles, mumps, and rubella (MMR)
• D. Hemophilus influenzae type B (Hib)

Correct answer: D

Rationale: The correct answer is D, Hemophilus influenzae type B (Hib) vaccine. Hib vaccine is crucial in preventing epiglottitis, a serious respiratory condition caused by Haemophilus influenzae type b bacteria. This vaccine is recommended for toddlers to protect them from developing epiglottitis. Choices A, B, and C are incorrect because while they are important vaccines for children, they do not specifically target the prevention of epiglottitis, unlike the Hib vaccine.

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