Nursing Elites

1. A 12-month-old infant has become immunosuppressed during a course of chemotherapy. When preparing the parents for the infant’s discharge, what information should the nurse give concerning the measles, mumps, and rubella (MMR) immunization?

• A. It should not be given until the infant reaches 2 years of age.
• B. Infants who are receiving chemotherapy should not be given these vaccines.
• C. It should be given to protect the infant from contracting any of these diseases.
• D. The parents should discuss this with their healthcare provider at the next visit.

Correct answer: B

Rationale: Live vaccines, like the measles, mumps, and rubella (MMR) vaccine, should not be administered to immunosuppressed infants, such as those undergoing chemotherapy. The weakened immune system of these infants may not be able to handle live vaccines safely, potentially leading to severe complications. Therefore, it is crucial to avoid giving live vaccines like MMR to infants receiving chemotherapy. Choice A is incorrect as delaying the MMR vaccine until the infant reaches 2 years of age is not the main concern in this scenario. Choice C is incorrect because although MMR vaccination is important for disease prevention, it should not be given to immunosuppressed infants. Choice D is incorrect as immediate action is needed to prevent potential harm from live vaccines in immunosuppressed infants.

2. A nurse is caring for an infant with phenylketonuria (PKU). What diet should the nurse anticipate will be ordered by the health care provider?

• A. Fat-free
• B. Protein-enriched
• C. Phenylalanine-free
• D. Low-phenylalanine

Correct answer: D

Rationale: A low-phenylalanine diet is required for infants with PKU to prevent the buildup of phenylalanine, which can lead to brain damage.

3. A 7-year-old child has an altered mental status, high fever, and a generalized rash. You perform your assessment and initiate oxygen therapy. En route to the hospital, you should be most alert for

• A. vomiting
• B. seizures
• C. combativeness
• D. respiratory distress

Correct answer: B

Rationale: Seizures are a common complication in children with high fever and altered mental status, indicating a risk of febrile seizures. While vomiting can occur with altered mental status, seizures are of higher concern due to the association with febrile illnesses in children. Combativeness may be a concern in some altered mental status cases but is not as common as seizures. Respiratory distress, although important, is not the primary concern in this scenario given the symptoms presented.

4. A child with a diagnosis of sickle cell anemia is admitted to the hospital with a vaso-occlusive crisis. What is the most important nursing intervention?

• A. Administering oxygen
• B. Administering pain medication
• C. Monitoring fluid intake
• D. Encouraging physical activity

Correct answer: B

Rationale: During a vaso-occlusive crisis in sickle cell anemia, the priority nursing intervention is administering pain medication. Pain management is crucial to alleviate the intense pain experienced by the child. While administering oxygen can help improve oxygenation, it is not the most critical intervention during a vaso-occlusive crisis. Monitoring fluid intake is important for overall care but is not the immediate priority during a crisis. Encouraging physical activity is contraindicated during a vaso-occlusive crisis as it can worsen the pain and the crisis itself.

5. After corrective surgery for hypertrophic pyloric stenosis (HPS) is completed, and the infant is returned to the pediatric unit with an IV infusion in place, what is the priority nursing action?

• A. Apply adequate restraints.
• B. Administer a mild sedative.
• C. Assess the IV site for infiltration.
• D. Attach the nasogastric tube to wall suction.

Correct answer: C

Rationale: The priority nursing action after corrective surgery for hypertrophic pyloric stenosis (HPS) is to assess the IV site for infiltration. This is crucial as it ensures proper fluid administration and prevents complications such as phlebitis or infiltration-related tissue damage. Applying restraints (Choice A) would not be appropriate in this situation as it is not related to the immediate post-operative care of an infant with an IV infusion. Administering a mild sedative (Choice B) is not indicated as the primary concern post-surgery is monitoring the IV site and the infant's response to the surgery. Attaching the nasogastric tube to wall suction (Choice D) is not the priority at this time, as assessing the IV site takes precedence to prevent potential complications.

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